Failure to Investigate and Resolve Resident Food Grievances
Penalty
Summary
The facility failed to ensure a proper response, action, and rationale to residents involved in group grievances, specifically regarding food quality and meal service. Multiple residents reported ongoing issues with the food, including poor taste, cold temperature, and inaccuracies in meal orders. Residents stated that their complaints were repeatedly brought up in resident council meetings and directly to dietary staff, but no meaningful changes were observed. Observations confirmed that food was delivered in an uninsulated cart with doors left open, contributing to cold meals. A review of grievance records from July to September revealed seven documented complaints related to food and mealtimes, with recurring themes of meal ticket inaccuracy and cold food. The facility's documentation of these grievances was incomplete, with several forms missing investigation and resolution sections. Meeting minutes from food committee and resident council meetings further confirmed that residents' concerns about meal accuracy and temperature persisted, especially during weekends and evenings. There was no evidence of corrective actions or staff training to address these issues. Staff interviews corroborated the lack of effective resolution. The dietary manager acknowledged that residents' food requests were sometimes missed and that it was common for nursing staff to retrieve missing items after trays were delivered. The DON and regional nurse consultant recognized that the facility's response to grievances was inadequate, with the DON expressing disappointment in the lack of documentation and corrective action. The facility's failure to fully investigate, document, and resolve resident grievances regarding food service constituted the deficiency.