Failure to Document, Track, and Resolve Resident Grievances Raised in Resident Council
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective and complete grievance policy, including failure to document, track, and promptly resolve residents’ grievances, and failure to provide written summaries of conclusions regarding grievances raised in resident council. The facility’s written Grievance Protocol states that the SSD is responsible for the grievance program, that grievances are to be recorded on a monthly grievance log, and that the Administrator and SSD are to evaluate the log for trends and develop action plans. Despite this, the facility’s grievance/complaint log contained no entries for three consecutive months, even though multiple concerns were documented in resident council minutes during that same period. Resident council minutes over several meetings documented repeated complaints and concerns from residents that met the facility’s own definition of grievances. These included reports of call lights not being answered in a timely manner, a CNA refusing to assist with compression socks and displaying a bad attitude, missing personal items such as sweatpants, coats, blankets, and a horse blanket, trash on floors in rooms and hallways, lack of hot water, no towels or wash rags, staff not knocking before entering rooms, flies, Hoyer lifts left in rooms, staff playing with their hair in the dining room, two-hour checks not being done, no shower aides resulting in no showers, and staff talking nastily to residents and showing bad attitudes. The resident council minutes for January, February, and March all showed that staff did not document any resolution of these concerns. Interviews with staff and leadership showed inconsistent understanding and implementation of the grievance process and confirmed that grievances raised in resident council were not being entered into the grievance log or consistently investigated. RN E stated grievances should be documented but was not aware of any grievances filed. The SSD reported that grievances should be referred to department heads and logged, but was unaware of the complaints documented in the resident council minutes and stated that he/she would only complete a grievance form if residents came directly to him/her. The AD stated that grievances were documented in resident council minutes, were sometimes taken to department heads, and were discussed in morning meetings, but was unaware of any grievance log and acknowledged complaints were not always handled immediately. The DON believed the SSD kept a grievance log and distinguished between formal grievances and undocumented complaints, while the Administrator stated grievances should be filed with the SSD, documented, and logged, but was unaware of specific complaints about staff and repeated call light issues documented in resident council. Together, these findings show that grievances voiced by residents were not consistently documented, tracked, or resolved in accordance with the facility’s grievance policy.
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