§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 review of clinical records and grievances lodged with the facility and staff and resident interviews it was revealed that the facility failed to demonstrate sufficient efforts to fully investigate, address and resolve grievances expressed by residents for two residents out of nine sampled (Resident 16 and Resident 5).
A review of a facility Concern Form dated January 13, 2019, completed by Resident 16, revealed that the resident was upset because she had to wait to have her "ice bucket" filled by staff. The resident also questioned the adequacy of staffing on all three shifts (7 AM to 3 PM, PM to 11 PM and 11 PM to 7 AM). The "Documentation of Facility Follow-up" section of the Concern Form was blank at the time of the review during the survey ending February 9, 2019. Documentation in the "Resolution of Concern," section of the form dated January 29, 2019, noted that the resident was "happy" with her care at the facility and noting that the resident had stated "things are just fine." The Registered Nurse completing this documentation noted that "the resident was pleasant that morning during the treatment she was administering and denied any complaints."
There was no documented evidence of the facility's efforts to resolve the specific the concerns, which the resident had expressed regarding refilling her "ice bucket" and the resident's impression that there was not enough staff on all three tours of nursing duty.
A review of the resident's most recent MDS Assessment (minimum data set assessment - a federally mandated standardized assessment process completed at specific intervals to plan resident care) completed upon admission, January 7, 2019, revealed that the resident was cognitively intact with a BIMS (Brief Interview for Mental Status - a tool to assess cognitive function) score of 15 out of 15.
Interview with Resident 16 on February 9, 2019, at 1:10 PM revealed that the resident clarified that when she referred to her ice bucket in her grievance she meant ice that was to be placed in a cooling device (machine) that was to be placed on her knee. The resident stated that she has to continually ring her call bell, to request that staff provide ice for the cooling device and many times the staff does not respond. The resident stated that the issue had resolved itself because she no decided to longer utilize the cooling device. Observation of the resident at the time of the interview revealed that she was not utilizing the device nor was it observed in the vicinity of her bed.
During the interview, Resident 16 further stated the facility the is not adequately staff and staff does not answer call bells, pass fresh ice water and are not attentive to resident needs. She confirmed these were among the issues she originally intended to voice in her grievance of Janaury 13, 2019. The resident confirmed that no facility staff had discussed her grievance with her so that she may be able to voice detailed complaints.
A review of the resident's clinical record confirmed that she was admitted to the facility for care following surgery for an infected right knee. A review of physician's orders initiated on January 3, 2019, which remained current at the time of survey ending February 9, 2019, revealed the resident was to have a cooling device applied to her right knee every two hours for 30 minutes.
According to review of the resident's treatment administration records for January 2019 and February 2019, the order remained active and the licensed nurses continued to document the application of the device through the time of the survey. The last documented application was February 9, 2019 at 1:00 PM for 15 minutes, which was during the surveyor's interview with the resident.
During a second interview with the resident 2:15 PM on February 9, 2019, the resident stated that about two weeks ago, she stopped using the device because the pain in her leg had lessened and the staff was still not bringing the ice. Resident 16 stated that she picked up the machine herself and placed it in her closet. Observation of the resident's closet confirmed that the machine was on the shelf in the resident's closet at the time of the interview.
At 2:40 PM on February 9, 2019, the Director of Nursing (DON) stated that she had interviewed Resident 16 regarding her concern dated January 16, 2019, "just a few minutes ago" (on February 9, 2019). The resident informed the DON that the ice she spoke of in the grievance was for the cooling device and the problem was resolved because she was no longer using the machine. However, the Director of Nursing was unaware that the device had not been discontinued by the resident's attending physician, but rather by the resident because nursing staff failed to provide the ice. The DON was also unaware that nursing staff continued to document the application of the device for the resident's use.
A review of a facility Concern Form dated January 28, 2019, completed by Resident 5, revealed that the resident stated that when Employee 7, a nurse aide, went to get her washed she would not take her to the bathroom and she was very rough with the resident. The resident stated that the aide "slammed her into her chair." Employee 7, was suspended related to the resident's allegation of rough care, but facility indicated that the aide was then trained on proper transfer techniques and returned to work. There was no documented evidence that the facility had addressed Employee 7's failure to assist the resident to the bathroom as the resident had requested.
Interview with Resident 5 on February 9, 2019, at 2:30 PM confirmed that she has to ask another staff member to help her to the bathroom on that day (of the grievance) because Employee 7 would not help her on that date.
Interview with the Director of Nursing on February 9, 2019, at 3 PM confirmed that the facility had not addressed Employee 7's failure to assist Resident 5 to the bathroom when requested.
Previously cited 11/19/18
28 Pa. Code 201.18(e)(1) Management
Previously cited 11/19/18, 10/16/18, 7/9/18, 4/17/18
28 Pa. Code 201.18(e)(4) Management
Previously cited 11/19/18
28 Pa. Code 201.29(i) Resident Rights.
Previously cited 11/19/18
28 Pa. Code 201.29(j) Resident Rights.
Previously cited 11/19/18, 10/16/18
| ||Plan of Correction - To be completed: 03/26/2019|
1. Residents #5, #16 are no longer at facility. A compliance investigation was initiated for Resident 16's grievance. Employees were suspended pending the investigation.
2. A comprehensive audit of resident grievances expressed within the last 30 days will be will be completed utilizing the QAPI Investigative tool to determine if they sufficiently demonstrate full investigation was completed and address and resolve concerns
3. The interdisciplinary team will be educated by the NHA/Designee on the Grievance Process by date of compliance 3/26/2019. The concern forms have been updated to allow NHA to sign off on resolution and completeness of investigation.
4. Random Audits will be completed by NHA/Designee utilizing the QAPI Investigation tool to monitor resolution of the concern weekly x8 weeks. Results will be reported to the QAPI committee for any necessary follow up.