Failure to Resolve Resident Grievances and Delayed Call Bell Response
Penalty
Summary
The facility failed to adequately address and resolve resident complaints and grievances, as evidenced by a review of facility policy, Resident Council meeting minutes, written grievances, and interviews with residents and staff. The facility's Grievance Policy requires that all grievances be considered and responded to in writing, with the Nursing Home Administrator (NHA) responsible for overseeing the process. Despite this, concerns about delayed call bell responses were repeatedly raised during Resident Council meetings and in written grievances. Specifically, one resident reported having to wait a long time for staff to respond to her call bell, and although the facility conducted call bell audits, the resident refused to sign the grievance as resolved, stating the issue persisted. The grievance was nonetheless marked as completed and resolved by the NHA. Interviews with two cognitively intact residents revealed ongoing issues with staff response times to call bells, with both reporting waits exceeding 30 minutes, particularly during the second and third shifts. One resident described experiencing a bowel incontinence episode due to delayed assistance. The NHA and Director of Nursing (DON) acknowledged that there was no documented evidence of completed resolutions for grievances raised during Resident Council meetings or for verbal complaints. These findings indicate that the facility did not follow its own grievance policy and failed to ensure prompt and effective resolution of resident complaints.