Failure to Provide Residents with Advocacy and Complaint Information
Penalty
Summary
The facility failed to ensure that residents received information and contact details for State and local advocacy organizations, including the State Survey Agency and the State Long-Term Care Ombudsman program, in a language and format they understood. Record review of monthly resident council minutes for the past six months showed no documentation of discussions regarding how to file a complaint with the state agency or review of ombudsman information. During a confidential group meeting, all seven residents present stated they did not know how to contact the ombudsman or file a complaint with the state agency, although they recalled being given a brief overview of the program and the ombudsman's name. The facility's admission packet was found to lack the required grievance procedure section and did not include state agency or ombudsman contact numbers. Interviews with the Administrator and Activities Director revealed that while residents were told they could file grievances with facility staff, information about filing complaints directly with the state or contacting the ombudsman was not routinely provided or documented. The Administrator stated that state and ombudsman information was only given if specifically requested by residents or families, and the Activities Director confirmed that the process for contacting the state agency was not explained or documented during resident council meetings. Although ombudsman information was posted at the facility entrance, residents were not consistently informed about their rights or the procedures for filing complaints with external agencies.