Ineffective Grievance Program and Unresolved Resident Concerns
Summary
The facility failed to implement an effective grievance program, as evidenced by ongoing issues with acknowledging, documenting, and resolving resident concerns. Over a six-month period, the grievance logs revealed persistent issues with call light response times, which were not adequately addressed. Additionally, there were grievances related to Activities of Daily Living (ADL) care not being provided, medications being left at the bedside, and medications not being administered in a timely manner. Despite staff education efforts, these issues continued to be a concern for residents. The Resident Council Minutes consistently showed unresolved grievances, with recurring complaints about call light response times, staff behavior, and dining services. The minutes also indicated that old business items were not always resolved, as evidenced by unchecked boxes meant to confirm resolution. Residents expressed dissatisfaction with various aspects of care, including the timeliness of laundry services, the availability of snacks, and the responsiveness of staff to their needs. Interviews with facility staff, including the Activities Director and Social Service Director, revealed that the grievance process was not effectively addressing resident concerns. The Social Service Director explained the grievance process, but the facility's performance improvement plan did not include audits for evening, night, and weekend shifts, which were times when grievances were notably unresolved. This lack of comprehensive auditing contributed to the ongoing issues with the grievance program.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was discharged on On , the NHA/Designee provided immediately re-educated to the Activity Director on the components of N042 with an emphasis on ensuring the Resident Council forms are completed with accuracy and grievances from Resident Council are acknowledged, documented, and resolved. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. On , NHA/Designee completed a quality review on grievances from Resident Council for the past six months ( ) to ensure voiced concerns were acknowledged, documented, and resolved. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. On , Vice President of Operations re-educated the management staff on the components of N042 with an emphasis on ensuring grievances from Resident Council are acknowledged, documented, and resolved. Newly hired management staff will be educated by the NHA or designee on ensuring grievances from Resident Council are acknowledged, documented, and resolved. On , Resident Council meeting will increase in frequency from biweekly to weekly to ensure grievances from Resident Council are acknowledged, documented, and resolved. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. Administrator/Designee to conduct audits weekly for 4 weeks, biweekly for 4 weeks, then monthly for 1 month to ensure the Resident Council forms are completed with accuracy and grievances from Resident Council are acknowledged, documented, and resolved. The findings of these quality monitoring reports are to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Penalty
A facility did not document, investigate, or communicate the outcome of a grievance after a resident's financial DPOA complained about a discharge and lack of notification. Although the complaint was acknowledged by the DON and intended for follow-up, no grievance was filed or investigated, and the DPOA received no response, resulting in noncompliance with grievance procedures.
A resident dependent on staff for hygiene reported being yelled at by a CNA after needing to be changed. The grievance was documented but not investigated or reported to the State agency. The Social Services Director and Administrator were unaware of the grievance, and the facility's grievance process was not followed.
Failure to File and Investigate Grievance for Resident's DPOA Complaint
Penalty
Summary
The facility failed to file and investigate a grievance for one resident out of three reviewed, as required by both state statute and the facility's own grievance policy. The policy mandates that any grievance, whether submitted orally or in writing by a resident or anyone acting on their behalf, must be documented, investigated, and communicated back to the complainant. In this case, the resident's Durable Power of Attorney (DPOA) visited the facility and expressed dissatisfaction to the DON regarding the resident's discharge and transfer without her approval or notification. The DPOA reported feeling upset and believed the facility should have communicated with her about the discharge. Upon review, it was found that the DPOA held financial authority only, as indicated by the Durable Power of Attorney form. Despite this, the DON acknowledged the DPOA's complaint and noted it, intending to pass it to the Social Service Director for follow-up per policy. However, the facility's grievance logs did not show any record of a grievance being filed or investigated regarding this complaint. Interviews with the DON, Social Services Assistant, and Nursing Home Administrator confirmed that no documentation existed to show the complaint was addressed, investigated, or communicated back to the DPOA. The Nursing Home Administrator stated that the facility's policy only required grievances to be filed by residents or those acting on their behalf, and after assessment, determined the financial DPOA was not acting on the resident's behalf in this context. However, both the DON and Social Services Assistant later confirmed that the DPOA had a valid complaint that should have been processed as a grievance. The facility did not investigate, resolve, or communicate the outcome of the complaint, resulting in noncompliance with statutory and policy requirements for grievance handling.
Plan Of Correction
N 042 1. On , a grievance was initiated by the Social Service assistant for resident #1 regarding the resident's fiduciary DPOA concern regarding resident #1 being discharged to another center without their knowledge. A final resolution was delivered to the fiduciary DPOA on . 2. By , an audit of current residents was completed by the Social Service Manager to ensure any resident with power of attorney is clarified on the sheet to ensure proper notification of any discharge plans. On the Director of Nursing was re-educated by the NHA to ensure any concerns are brought to the interdisciplinary team as a grievance and a conclusion/resolution is brought to the person filing the grievance. By staff were re-educated on the Grievance process by the Staff development coordinator. 3. Random interviews of residents/family/visitors 3 times a week for 12 weeks to ensure all concerns are brought through the grievance process. Interviews to be conducted by social services. 4. Interviews will be brought to the Quality Assurance and Assessment/Quality Assurance Performance Improvement committee for a minimum of three months or until substantial compliance is achieved.
Failure to Follow Grievance Process for Resident Complaint
Penalty
Summary
The facility failed to ensure that staff were knowledgeable of and followed their grievance process for a resident who had filed a complaint. The resident, who was dependent on staff for toileting hygiene and required substantial assistance for personal hygiene, reported being yelled at by a CNA after needing to be changed for the second time. The grievance was documented in the Resident Grievance Log, but the investigation findings section was left blank, and there was no follow-up or report submitted to the State agency. The Social Services Director, who was responsible for overseeing grievances, stated that grievances were discussed daily during morning meetings, but the Administrator confirmed that the specific grievance was not brought to her attention. The grievance form was handed to the Social Services Director by the Unit Manager, but it was not read or investigated as required. The facility's policy intended to support residents' rights to voice complaints and resolve them promptly, but in this case, the grievance process was not properly followed, and the grievance was not addressed or reported as necessary.
Plan Of Correction
Grievance was submitted to AIRS system by NHA. A comprehensive review of all grievances for the months of [insert months] was conducted by the Regional Vice President of Operations, Executive Director, and Social Services Director to ensure adherence to facility policy. No new issues found. 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff on the grievance and reporting process, postings, and placement of grievance forms. 3. All grievances are reviewed by ED, SSD, and DON daily; supervisor calls and reviews grievances with ED, SSD, DON, or designee on weekends. 4. Grievance policy reviewed by Executive Director in resident council meeting on [insert date]. 5. A quality review is conducted weekly by ED/DON or SSD on grievances and reportable incidents. A quality review will be completed by the Executive Director/designee of grievances and reportable incidents to ensure the policy/process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
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