Failure to Provide and Communicate Anonymous Grievance Process
Penalty
Summary
The facility failed to ensure residents and family members had a method to file grievances anonymously and were provided information on how to do so, as required by its own policy and licensure regulations. Record review of the undated facility policy titled "Resident and Family Grievances" showed that information on how to file a grievance or complaint would be available and that a grievance may be filed anonymously. However, review of the undated Admission Agreement showed that while residents were encouraged to voice grievances and suggestions to the administrator, DON, social service director, or resident council, it did not include any information on how to file a grievance anonymously. During interviews, the SSD, who serves as the facility’s grievance officer, stated that residents or families wishing to file a grievance would notify a staff member, who would assist them with the process, and acknowledged uncertainty about how a resident could file a grievance anonymously other than sliding it under the SSD’s office door. The SSD confirmed that although the policy states a grievance may be filed anonymously, residents and families are only educated on the grievance process during admission paperwork and are not given education or instruction on how to file grievances anonymously. The FA reported that the facility has an open-door policy for grievances and that residents and families are encouraged to notify staff with grievances, but did not identify any established anonymous grievance mechanism. This deficiency had the potential to affect all 59 residents in the facility.
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