Failure to Provide Accessible Grievance Information and Grievance Official Contact Details
Penalty
Summary
The deficiency involves the facility’s failure to provide required information to residents about how to file grievances and how to contact the designated grievance official. On the North nursing unit, surveyors observed a grievance box with forms available, but there was no information posted or provided regarding the grievance official’s name and contact information, residents’ right to file grievances orally, in writing, or anonymously, or the expected time frame for completion of the grievance review. The same issue was identified on the South nursing unit, where a grievance box with forms was present but lacked the required informational details. On the West nursing unit, surveyors were unable to locate a grievance box at all, indicating that residents on that unit did not have the same visible access to grievance forms as on other units. In the dining area, a grievance box with forms was present, but again, there was no accompanying information about the grievance official’s identity and contact information, the right to file grievances orally, in writing, or anonymously, or the expected time frame for review completion. These observations showed that residents did not have complete and accessible information about the grievance process in multiple common areas and units. Surveyors also observed a bulletin board in a hallway leading to the dialysis area, activities room, and conference room where information about the grievance official and filing grievances was posted. However, this information was placed far above the eyesight of a person seated in a wheelchair, limiting accessibility for residents who use wheelchairs. During an interview, the Nursing Home Administrator confirmed that the facility failed to provide information regarding how to file a grievance and information on the grievance official on all three nursing units, corroborating the surveyors’ findings.
Plan Of Correction
The information on the grievance box has been corrected to include the Grievance official's name and contact information, the right to file grievances orally, in writing, or anonymously and the expected time frame for completion of the grievance review. This information has been posted at eyesight level of a person seated in a wheelchair. A Grievance box has been added to the West Unit. The Administrator has educated the Social Worker who is the Grievance officer on the required posting with the required information. A new grievance form/process will be put into place to monitor the time frame for completing the grievance in the expected time frame. The Administrator/Designee will Audit for the placement and required information for the Grievance regulation and 10% of resident grievances for the timely completing weekly times four and monthly times four. Results of these audits will be presented to the QAPI committee for review and 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.