§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.
§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.
§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.
§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Based on a review of facility policy, resident group interview, and staff interview, it was determined that the facility failed to ensure residents were notified of the procedure for filing grievances anonymously on two of two nursing units (Second Floor Nursing Unit and Third Floor Nursing Unit).
Review of the facility policy undated and titled, "Grievance Policy," revealed that the policy is for residents who may have concerns and the facility will seek to resolve them. Further review of the policy revealed that concerns should be made to the Director of Nursing, Administrator, Nursing Supervisor, or Department Head. The policy further revealed that a "concern box" was located in the building.
During a resident group interview on January 11, 2019, at approximately 1:30 p.m. with ten alert and oriented residents from the Second and Third floors revealed that these residents were unclear on the procedure of filing a grievance anonymously. This group interview further revealed that the residents could not identify the grievance officer and were not aware of a "concern box" in the building.
An observation on the Third Floor Nursing Unit on January 14, 2019, at approximately 10:00 a.m. failed to reveal the process of filing a grievance anonymously, failed to reveal that Grievance/Concern Forms were visible on the unit, and failed to reveal a "concern box."
An observation on the Second Floor Nursing Unit on January 14, 2019, at approximately 12:15 p.m. failed to reveal that the process of filing a grievance anonymously was displayed and also failed to reveal the presence of a "concern box" on the unit. Observation of the outside of the dining room area on the Second Floor Nursing Unit revealed forms located on a shelf with a sign stating,"submit comments to receptionist."
An interview on January 14, 2019, at approximately 1:15 p.m. with the Director of Nursing confirmed that the residents and/or families were unable to file an anonymous grievance and further confirmed that grievance/concern forms were not accessible to residents or families.
The facility failed to ensure residents were notified of the procedure for filing grievances anonymously.
28 Pa. Code 201.18(b)(3) Management
Previously cited 03/30/18, 01/17/17
28 Pa. Code 201.29(i) Resident rights
| ||Plan of Correction - To be completed: 02/27/2019|
1. Concern boxes will be made available for anonymous grievances. Grievance procedure, indicating grievance official will be posted by the grievance forms.
2. Current residents and families will be provided with the written grievance procedure, which includes how to file an anonymous grievance, the name and contact information of the grievance officer and the location of the concern boxes. Grievance procedure will be reviewed at the resident council meeting.
3. Staff will be educated on the grievance procedure by the Nursing Home Administrator or designee.
4. Resident, Staff, and Family interviews will be conducted by Social Services or designee to verify knowledge of the grievance procedure. Results of these audits will be reviewed at the facility QAPI meeting.