Failure to Document and Address Resident Grievances Regarding Call-Light Delays and ADL Care
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of documented grievances for a resident who reported significant delays in call-light response and concerns related to activities of daily living (ADL) care. The resident, who was alert, oriented, and verbally responsive, had been admitted with left-sided and recent right-sided surgery, resulting in significant self-care limitations. Her care plan required assistance with all ADLs, including bathing, eating, hygiene, mobility, toileting, transfers, and skin assessments, and she relied on the call bell for help. The resident reported waiting approximately four hours for assistance after activating her call light during nighttime hours and expressed dissatisfaction with the quality of care received. She stated that she communicated these concerns to nursing staff, but no improvements were observed. The resident also indicated that CNAs told her they were responsible for 16 residents and did not have adequate time to provide timely care. Additionally, her family reported concerns to the Administrator but perceived the response as indifferent. The resident further stated that when she requested to receive ADL care before other residents due to her functional limitations, staff responded that permanent residents were prioritized over her, and her complaints were not addressed by Administration. Interviews with staff revealed that while the resident's complaints were communicated to the Director of Nursing and documented in the facility's electronic system, no formal grievance documentation was submitted on her behalf. The Social Worker confirmed that no grievance forms had been received from the resident or staff, and the Director of Nursing stated that no complaints had been received from the resident or her family. The facility's grievance procedure requires documentation and resolution within three days, but no documentation existed for this resident's grievances.
Plan Of Correction
Resident #75- grievances regarding ADL care and call light response was documented and addressed. A quality review of current residents was conducted to ensure there is no undocumented grievances regarding delay in call light response and concerns related to activities of daily living (ADL) care. The Director of Nursing will educate the Nursing staff on ensuring that grievances with resident's concerns are documented and addressed. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that staff is documenting grievances with resident's concerns. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.