Failure to Document and Address Resident Grievances Regarding Call-Light Delays and ADL Care
Summary
A deficiency was identified when the facility failed to provide evidence of documented grievances for a resident who reported significant delays in call-light response and concerns related to activities of daily living (ADL) care. The resident, who was alert, oriented, and verbally responsive, had been admitted with left-sided and recent right-sided surgery, resulting in significant self-care limitations. Her care plan required assistance with all ADLs, including bathing, eating, hygiene, mobility, toileting, transfers, and skin assessments, and she relied on the call bell for help. The resident reported waiting approximately four hours for assistance after activating her call light during nighttime hours and expressed dissatisfaction with the quality of care received. She stated that she communicated these concerns to nursing staff, but no improvements were observed. The resident also indicated that CNAs told her they were responsible for 16 residents and did not have adequate time to provide timely care. Additionally, her family reported concerns to the Administrator but perceived the response as indifferent. The resident further stated that when she requested to receive ADL care before other residents due to her functional limitations, staff responded that permanent residents were prioritized over her, and her complaints were not addressed by Administration. Interviews with staff revealed that while the resident's complaints were communicated to the Director of Nursing and documented in the facility's electronic system, no formal grievance documentation was submitted on her behalf. The Social Worker confirmed that no grievance forms had been received from the resident or staff, and the Director of Nursing stated that no complaints had been received from the resident or her family. The facility's grievance procedure requires documentation and resolution within three days, but no documentation existed for this resident's grievances.
Plan Of Correction
Resident #75- grievances regarding ADL care and call light response was documented and addressed. A quality review of current residents was conducted to ensure there is no undocumented grievances regarding delay in call light response and concerns related to activities of daily living (ADL) care. The Director of Nursing will educate the Nursing staff on ensuring that grievances with resident's concerns are documented and addressed. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that staff is documenting grievances with resident's concerns. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Penalty
Two residents experienced deficiencies in the facility's grievance process, including lack of proper investigation, documentation, and communication regarding their complaints. One resident did not receive follow-up after reporting inappropriate staff behavior, while another was left in soiled conditions for an extended period without timely care or proper reporting. Staff interviews revealed confusion about responsibility for grievance resolution, and required documentation was incomplete or missing.
A resident's representative filed multiple grievances about the facility's failure to pay the resident's phone bill. Despite assurances from the business office and the former NHA that the bill was paid, the representative found it was not. The representative was told to pay the bill herself with a promise of reimbursement, which had not occurred, leading to ongoing frustration and unresolved grievances.
Failure to Ensure a Functioning Grievance Process
Penalty
Summary
The facility failed to ensure a functioning grievance process for two residents, as required by state statute. For one resident, a grievance was verbally communicated to the Social Service Assistant regarding two CNAs having personal conversations while providing care. The grievance form was completed, and the CNAs were identified and verbally educated. However, there was no documentation indicating whether the resident was satisfied with the resolution, and the resident later stated that no one had spoken to her about the concern or provided a response. Interviews with staff revealed confusion about who was responsible for investigating and resolving the grievance, with some staff unaware of the complaint or not participating in the investigation. Another incident involved a resident who was found covered in feces after reportedly waiting for an extended period before being changed. The CNA assigned to the resident was educated about the importance of prompt care, and a "teachable moment" document was placed in the personnel file. However, the form was not signed by the presenter or recipient, and the section indicating whether the grievance was reportable to the state agency was left blank. The resident was totally dependent on staff for toileting, and the care plan reflected this need. The NHA confirmed that the resident should have been changed at least every two hours and acknowledged that the incident could be considered neglect, but it was not reported. Both cases demonstrate a lack of proper documentation, follow-up, and communication with the residents regarding their grievances. The facility did not ensure that grievances were thoroughly investigated, resolved in a timely manner, or that residents were informed of the outcomes, as required by policy and regulation. The absence of clear documentation and communication contributed to the deficiency cited by surveyors.
Plan Of Correction
Resident #1 was interviewed regarding the incident, and upon conclusion of the interview, the resident was satisfied with the outcome of the decision made by administration in relation to the submitted grievance. Reportable incident completed regarding this issue on . Additional services offered to the resident to provide additional support. Nursing assessments were completed to ensure there were no adverse effects to the resident. No adverse effects were noted. Grievance log and grievances reviewed for the previous 3 months by the NHA and Social Services Director (SSD). There were no other grievances that were found to be reportable events. Resident interviews were completed for residents with above 10 to ensure that there were no outstanding concerns or allegations that were not addressed. Skin assessments were completed for residents with less than 10. No additional findings were noted at the time of evaluation. Grievances are reviewed five times a week by the IDT to ensure a timely response. The grievance log and grievances will be audited weekly by the SSD or designee, and NHA or designee, to ensure that grievances are completed timely and that allegations were addressed. This will be an ongoing practice implemented as part of the facility operations. Room rounds continue to be completed five times a week by the IDT to ensure the resident is monitored and has no concerns. Education was completed with staff to review the grievance process. Education was provided by IDT members to staff, and the IDT was educated by the company VP of Risk Management. The grievance process was reviewed at the resident council meeting with residents. Residents confirmed their understanding of the process. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Social Services Director or designee.
Failure to Resolve Resident Grievance Regarding Phone Bill Payment
Penalty
Summary
The facility failed to ensure a prompt resolution to a grievance for one of the sampled residents. The resident's representative filed multiple grievances regarding the payment of the resident's phone bill. Initially, the representative was informed by the business office that the bill would be paid, but it was not. The grievance form indicated that the former Nursing Home Administrator had signed off that the bill was paid and the grievance resolved, but this was not the case. Subsequent grievances were filed by the representative, expressing frustration that the phone bill was not completely paid and that she was told to pay the bill herself with the promise of reimbursement. Despite the grievance log reflecting that the issue was resolved, the representative reported that she had not been reimbursed and was not receiving responses from the facility. The Social Service Director and the current Nursing Home Administrator were involved in addressing the grievances, but the issue remained unresolved at the time of the report.
Plan Of Correction
The Social Services Director spoke with resident #3's responsible party to communicate the facility's effort to a prompt resolution. The phone bill monies were withdrawn from resident #3's personal funds account and reimbursed to the responsible party. The facility will manage resident #3's monthly phone bill going forward. The facility will manage residents' personal accounts for those that the facility is the designated payee. The Social Services Director and Nursing Home Administrator conducted a complete audit of all grievances in the past 2 months to ensure accuracy and prompt resolutions. No further corrections were identified. The Social Services Director or designee will conduct interviews of 4 random residents/responsible parties 5 times a week for 2 weeks, then 2 times a week for 4 weeks, then monthly for 2 months. The Social Services Director was re-educated by the Nursing Home Administrator to ensure a prompt resolution to a resident grievance. The Social Services Director or designee will re-educate the current staff on the resident grievance policy and procedure and accurate use of the grievance form with prompt resolution. Findings from the quality review audits will be reviewed and discussed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for 3 months. Non-compliance will be reviewed by the QAPI committee with direct changes to the plan as deemed necessary to ensure ongoing and sustained compliance.
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