Failure to Document and Track Resident Council Concerns on Required Response Form
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy for documenting and tracking concerns raised during resident council meetings. Review of resident council minutes from two meetings showed that residents reported problems with timely toileting assistance, specifically requesting that nurses regularly check on residents who use the restroom often at least every two hours, and concerns that call lights were not being answered in a timely manner. These concerns were recorded in the council minutes but were not transferred to or documented on the facility’s Resident Council Response Form, which is the tool designated by policy to formally record issues and track their resolution. The Activities Director, who had been in the role for about a month, reported being unaware of prior resident council concerns and stated that council minutes should be shared with department heads so they can investigate and address issues. The DON acknowledged that the facility was aware of the residents’ concerns about delayed call light response and the need for assistance with toileting and hygiene at least every two hours, and stated that staff in-services were provided. However, the DON confirmed that the Resident Council Response Form was not used as required by the facility’s Resident Council policy. The policy specifies that the Response Form will be used to track issues and their resolution, that the responsible department will address the concerns, and that the QAPI committee will review resident council information as part of its quality review. Because the form was not used, the issues raised in the two council meetings were not formally tracked or integrated into the QAPI review process.
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