Failure to Address and Document Resident Council Grievances
Penalty
Summary
The facility failed to consider and act upon the views, grievances, and recommendations of the resident council regarding issues of resident care and life in the facility. Review of resident council meeting minutes from September through November showed that concerns such as missing clothing, food preferences, transportation issues, and problems with room landlines were documented, but there was no evidence of investigation, follow-up, or communication of results or rationale back to the resident council. The facility did not document responses or actions taken to address these group grievances, nor did it provide written decisions or maintain records as required by policy. Interviews with facility staff, including the DON, ADON, AED, and nursing staff, revealed that while individual grievances were generally addressed and documented, there was confusion and lack of clarity regarding the process for handling and documenting group grievances raised by the resident council. Staff members acknowledged that grievances brought up in resident council meetings should be addressed, but several were unsure whether these group grievances were documented or how they were resolved. The DON and other administrators indicated that they were not aware of the status or location of group grievance documentation for the months in question, and there was no system in place for tracking or responding to these concerns as a group. Facility policy required prompt resolution of grievances, written decisions, and maintenance of evidence regarding the results of all grievances. However, the lack of documentation and follow-up for resident council group grievances demonstrated a failure to comply with these requirements. This deficiency was identified through interviews, record reviews, and policy examination, which collectively showed that the facility did not ensure resident council concerns were investigated, resolved, or communicated back to the group as required.