Failure to Respond to Resident Council Concerns About Inadequate Staff Response
Penalty
Summary
The deficiency involves the facility’s failure to respond to resident council concerns and grievances regarding inadequate staff response to care needs over a six‑month period. Resident council minutes from multiple meetings documented repeated complaints about delayed call light response times, lack of licensed nursing response, insufficient staff on units due to nurse aides taking breaks together, late meals, and residents not being assisted out of bed or to and from bed in a timely manner. Additional concerns included nurse aides being too busy to complete restorative care, staff not checking on residents, and residents not being assisted from the dining room after the evening meal. A facility‑provided letter signed by nine residents further described residents being neglected, dismissed, or left unattended by aides or employees who were frequently using cell phones or earbuds for personal activities instead of providing care. The resident letter also reported residents being left in the dining room until late in the evening while aides sat in breakrooms using their phones, residents not being fed, residents left in soiled briefs, and residents waiting hours to be transferred from wheelchairs to beds. It described aides carrying hot plates in one hand and cell phones in the other while residents waited, and aides vaping in hallways and in the employee bathroom. During a resident group interview, nearly all participating residents voiced ongoing concerns that facility administration had not resolved these issues related to inadequate staff response to care needs. The facility’s later documentation of its response to resident council concerns did not show that staff had been instructed or educated to address the timeliness of getting residents out of bed or the length of staff breaks, and by the end of the survey, evidence of such education or instructions was not provided. The Nursing Home Administrator confirmed that the facility failed to respond to resident council concerns and failed to do so in a timely manner for the entire review period.
Plan Of Correction
A Family Council meeting is scheduled for May 8th at 4:30 pm with the Management staff to discuss concerns regarding call light response, resident transfer status and bed mobility this is a new intervention to improve communication with families The follow-up of these conversations/concerns will be documented by the Social Worker in the appropriate location and in a timely manner. A Family Council meeting will be scheduled monthly The DON has created an assignment sheet that will clearly inform staff when, how long, and where their break time can be taken. Staff will be educated by the DON/Designee on the Call light policy and the new assignment sheet, which will show the scheduled break time of staff including how long the break will be. Education will be provided to the staff responsible for resident council and how to address concerns brought up in the meetings Audits will be completed by the DON/Designee on the call light policy, the new assignment sheet and timely response to council concerns weekly times four and monthly times two. Results of these audits will be reviewed by the QAPI committee for further recommendations.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.