Failure to Create Plan of Action for Resident Council Concerns
Penalty
Summary
The facility failed to ensure that a Plan of Action form was created in response to concerns raised by residents during resident council meetings, as required by the facility's own policy and procedure. Specifically, meeting minutes from two separate resident council meetings documented complaints from residents about long wait times for staff assistance during shift changes. Although the Activities Director reported these complaints to the Director of Nursing, no Plan of Action form was submitted as mandated by the facility's policy. The facility's policy states that the Activities Director is responsible for referring resident concerns to appropriate personnel and that a Plan of Action form should be submitted to address these concerns or suggestions. The lack of a Plan of Action form for the complaints about wait times meant that the concerns raised by residents were not formally addressed or tracked according to established procedures.