§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 observations, review of facility policies, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to post their grievance policy in prominent locations throughout the facility for three of three nursing units and failed to investigate concerns voiced by a resident representative for one out of 42 residents reviewed (Resident R11).
Review of facility policy, "Grievance, Complaints and Suggestions," dated September 14, 2017, revealed that "Communities have a mechanism in place to assist the resident, and/or their resident representative, in voicing conflicts about care decisions, grievances, or complaints ... This policy will be posted in prominent locations throughout the facility." Continued review revealed that "Each community must designate a Grievance Officer ... The name and contact information of the Grievance Officer must be posted on each neighborhood and at the main entrance of the health center ... The Grievance Officer as identified will maintain complaint logs. All grievances/complaints or suggestions shall be maintained on the Grievance Log. The resident and/or their resident representative, will be kept informed of the process taking place to resolve the grievance, complaint or suggestion ... residents/resident representative have a right to a written grievance decision"
An interview on May 15, 2019 at 11:15 a.m., during the group meeting that was held with nine alert and oriented residents revealed that Resident R11's representative (niece) filed a grievance related to a missing personal item for Resident R11. The grievance was filed approximately one to two weeks prior to the group meeting on May 15, 2019. Resident R11 reported during the group meeting that the facility never responded to the resident or the resident's niece about the results of the investigation into the resident's missing item (perfume).
Review of the facility's concern logs for the past five months revealed that Resident R11's concern was not listed on the log.
Interview with the director of nursing on May 16, 2019, at 10:00 a.m. revealed that the facility must have lost the grievance form for Resident R11.
A tour of the facility completed between 10:00 a.m. and 10:30 a.m. on May 17, 2019, revealed that the facility grievance policy was not posted on any of the nursing units and that there were no grievance forms readily available on any of the nursing units.
Interviews on May 17, 2019, at 10:00 a.m., with Employee E3, registered nurse and Employee E4, unit clerk, from the first floor nursing unit, confirmed that neither the grievance policy nor grievance forms were posted or readily available on the unit.
Interviews on May 17, 2019, at 10:20 a.m., with Employee E6, licensed practical nurse, and Employee E5, nurse aide, from the second floor nursing unit, confirmed that neither the grievance policy nor grievance forms were posted or readily available on the unit.
Interview on May 17, 2019, at 10:30 a.m., with Employee E7, registered nurse, from the third floor nursing unit, confirmed that neither the grievance policy nor grievance forms were posted or readily available on the unit.
Interview on May 17, 2019, at 11:05 a.m. with Employee E8, Regional Nurse, confirmed that neither the grievance policy nor grievance forms were posted or readily available by the health center entrance and stated that they should be.
The facility failed to post their grievance policy in prominent locations throughout the facility and failed to investigate a concern voiced by one resident's representative.
28 Pa. Code 201.29(a)(b)(d) Resident rights.
28 Pa. Code: 201.18(b)(1) Management.
Previously cited 4/12/18 and 1/3/17
28 Pa. Code: 201.14(a) Responsibility of licensee.
Previously cited 4/12/18 and 1/3/17
| ||Plan of Correction - To be completed: 07/01/2019|
1. Resident R11's perfume has been found and returned to the resident. Grievance policy has been posted in prominent locations throughout the community and includes the Grievance Officer Contact and grievance forms.
2. Grievances in the past 15 days have been reviewed to ensure that the results of the grievance investigations were communicated to the resident/family member. Postings and forms are as stated above.
3. Re- education will be given to the Grievance Officer and the Social Service staff regarding the need to provide grievance results to the residents or their representative. The Nursing supervisors and Nursing Administration were re-educated on the locations of the postings and the availability of the grievance forms. Residents will be re-educated at resident council.
4. An audit of Grievance Log will be completed weekly for 4 weeks and then monthly for 2 months to ensure that results of investigations have been communicated to the resident or their representative. An audit will be completed to verify that the postings are in place and that the forms are readily available weekly x 4 weeks and then monthly X2. Audits results will be forwarded to the Quality Assurance Process Improvement Committee.