Failure to Promptly and Consistently Resolve Resident Grievances Related to Incontinence Care and Call Bell Response
Penalty
Summary
The facility failed to ensure prompt and consistent efforts were made to resolve resident grievances, specifically in relation to incontinence care and call bell response times. In one instance, a resident with hemiplegia and hemiparesis, who was dependent on staff for toileting, experienced an episode of incontinence while preparing to attend church. The resident and their representative reported that staff informed the resident that if incontinence care was provided, the resident would not be able to attend church. As a result, the resident attended church in a soiled brief. Documentation showed that the Manager on Duty was informed of the incident well after lunch, and although the resident was eventually provided care, there was no thorough investigation or communication of the facility's efforts to resolve the grievance to the resident or their representative. Staff interviews revealed that key personnel were unaware of the grievance until much later, and statements were not collected in a timely manner. The facility also failed to address and resolve repeated grievances and concerns related to staff response to call bells, as reported by multiple residents and the Resident Council over a nine-month period. Grievance forms and Resident Council Meeting Minutes documented ongoing complaints about delayed call light responses, staff turning off call bells before needs were met, and staff being inattentive or unavailable. Investigations into these grievances were often incomplete, lacking documentation of whether actual delays occurred or what specific actions were taken. In several cases, there was no follow-up with residents or their families regarding the facility's efforts to resolve the grievances, and some grievances remained unresolved for extended periods. Observations and interviews further confirmed ongoing issues with call light response times. Residents reported waiting significant periods for assistance, and staff acknowledged challenges in responding promptly due to workload and staffing levels. Facility leadership and consultants were unable to specify targeted response times or provide evidence of systematic efforts to address the pattern of grievances. There was also no documentation that these concerns were addressed in the facility's Quality Assurance and Performance Improvement (QAPI) committee.