Failure to Provide Anonymous Grievance Filing System
Penalty
Summary
The facility failed to provide a system that enables residents to file anonymous grievances, as required by their own policy and regulatory standards. Observations revealed that grievance forms were not publicly available in common areas where grievance information is posted. Instead, forms were only accessible at the nurses' station and administration office, requiring residents to request them directly from staff. Interviews with the Director of Nursing (DON) and other staff confirmed that there was no process in place for residents to submit grievances anonymously without staff involvement. Interviews with six residents during a Resident Council meeting indicated that residents were unaware of how to file an anonymous grievance, with several stating they would need to ask staff for a form. Record reviews showed that these residents had no cognitive impairment, as indicated by their BIMS scores. The facility's grievance policy allows for anonymous complaints, but in practice, residents could not access forms without staff assistance. Staff interviews further confirmed that grievance forms were kept in locations inaccessible to residents without staff involvement.