§483.10(j) Grievances.
§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.
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Observations:
Based on interviews, review of clinical records and review of resident grievances, it was determined that the facility failed to provide 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, the date the written decision was issued; and evidence that the resident was notified of the outcome of their grievance for 1 out of 3 residents reviewed (Resident R1):
Findings include:
Review of the facility policy, "Grievance/Concern," with a revision date of January 8, 2024, indicated that the Nursing Home Administrator (NHA) will serve as the Grievance Officer who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, and maintaining the confidentiality of all information associated with grievances. The policy also indicated that the NHA was responsible for issuing written grievance decisions to the resident and coordinating with state and federal agencies, as necessary regarding specific allegations.
Continued review of the policy indicated that upon receipt of the "Grievance/Concern Form," the NHA or designee will document the grievance/concern on the "Grievance Concern Log," and when the grievance is logged, the NHA and appropriate department manager will be notified. Review of the policy also indicated that the department manager will contact the person filing the grievance to acknowledge receipt, investigate the grievance, and take corrective actions if needed. In addition, the policy stated that the department manager will also notify the person filing the grievance of resolution in a timely manner. The policy also indicated that if the grievance/concern is unable to be resolved satisfactory, the resident/representative will be referred to the facility's Market President for assistance.
Review of the resident's May 2024 physician orders indicated that the resident was admitted into the facility from the hospital on May 10, 2024 for rehabilitation services with the following diagnosis: spinal stenosis; right foot drop; rotator cuff tear or rupture of left shoulder, and hypertension (high blood pressure).
Review of a nursing note on May 22, 2024, at 2:10 p.m. indicated that the resident was discharged back to her home.
Review of a "Grievance/ Concern Form" submitted by the resident dated May 13, 2024, indicated that Resident R1 reported the following:
(1) Resident reported that on Friday night (May 10, 2024) a nurse aide was not very friendly. The resident explained that while helping her get changed, the nurse aide threw the resident's pants on her bed, instead of handing them to the resident.
(2) Resident reported that it takes 45 minutes to answer her call bell
(3) Resident reported that the a nurse aide scratched her when she was helping the resident put on her socks.
The "Grievance/Concern Form" indicated that the concern was reported to Employee E3, a representative from the facility's Guest Services Department.
Review of the "Investigation" section of the "Grievance/Concern Form" indicated that the following actions were taken to investigate the grievances/concerns:
1."customer service education."
2"call bell audit attached. did not take 45 minutes."
3. "wound was cleaned let nursing supervisor know."
Review of the May 13, 2024 "Grievance Concern Form" filed by the resident did not include information such as, but not limited to, the steps that the facility took to investigate the grievance, including, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), or a statement as to whether the grievance was confirmed or not confirmed. If confirmed, there was no documentation to ensure that appropriate corrective action was taken regarding certain allegations of abuse and/or neglect is identified ( for example). Review of the grievances also did not include the date that the written decision was issued:
Review of the call bell audit that was completed indicated that the audit was done on May 20, 2024, which was 7 days after Resident R1 filed the grievance. Continued review of the grievance did not include any information regarding who the nurse aide was, no documentation on any interviews conducted with the identified nurse aide or other nursing staff who worked Friday night regarding the resident's allegation against the nurse aide.
The "Findings/Conclusion of Investigation" of the above referenced grievance was left blank.
The "Recommended Corrective Action" section of the grievance stated, "customer service education being done in June."
The "Resolution of Grievance/Concern," section that documents whether the grievance/concerns were resolved, was checked-marked "yes." The section to indicate the method that was used to notify the resident and/or patient representative was left blank. The section asking for the name of the person who completed the grievance, and the date that the grievance was completed were both left blank.
Review of a "Grievance/ Concern Form" submitted by the resident dated May 20, 2024, indicated that Resident R1 reported the following:
(1)Resident reported that her neighbor next door yells at night and keeps her up.
(2) Resident reported that it took 45 minutes to answer her call bell when she was in the bathroom and needed staff to open the bathroom door to help her out of the bathroom.
(3) Resident reported that another resident came into her room sometime after lunch on May 18, 2024, cursed at her and told her (Resident R1) to get out of her room. Resident R1 felt that this resident was being aggressive.
The "Grievance/Concern Form" indicated that the concern was reported to Employee E3, a representative from the facility's Guest Services Department.
Review of the "Investigation" section of the "Grievance/Concern Form" indicated that the following actions were taken to investigate the grievances/concerns:
(1)Patient discharged
(2)Conduct call bell audit
Review of the May 20, 2024 "Grievance Concern Form" filed by the resident did not include information such as, but not limited to, the steps that the facility took to investigate the grievance, including, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), or a statement as to whether the grievance was confirmed or not confirmed. If confirmed, there was no documentation to ensure that appropriate corrective action was taken regarding certain allegations of abuse and/or neglect is identified ( for example). Review of the grievances also did not include the date that the written decision was issued:
The "Investigation" section of the "Grievance/Concern Form" did not include, any evidence that any investigation was conducted regarding concerns that the resident had about her next door neighbor yelling at night and keeping her up. There was no information in the grievance indicating that resident's specific concern with call bells regarding staff not answering her call bell to assist her out of the bathroom was investigated (e.g. interviews with staff assigned to the resident on that particular shift). There was also no evidence that the resident's investigation regarding the incident of a 2nd resident who came in her room on May 18, 2024 that was listed on her grievance.
The "Findings/Conclusion of Investigation" of the above referenced grievance stated (1) call bells answered timely (2) care plan updated to keep patient from room (3) neighbor discharged.
The "Recommended Corrective Action" section of the grievance was left blank.
The "Resolution of Grievance/Concern" section that documents whether the grievance/concerns were resolved was checked-marked "yes." The section to indicate the method that was used to notify the resident and/or patient representative was left blank. The section asking for the name of the person who completed the grievance and the date that the grievance was completed were both left blank.
Continued review of the "Grievance /Concern Form," did not show evidence that the resident was contacted regarding the outcome of the grievance investigations.
During an interview with Resident R1 on June 10, 2024, at 12:43 p.m. Resident R1 reported the concerns that she reported to Employee E3 on May 13, 2024, and May 20, 2024, regarding her concerns that are listed in the above-referenced grievances. Resident R1 reported that she filed a grievance but did not receive any information from the facility regarding the outcome of her written grievances.
During an interview with the Director of Nursing (DON) and Employee E3 on June 10, 2024, at 2:02 p.m. a discussion about the missing information in the resident's grievance instigation was reviewed. It was confirmed during this time that there was no documentation to show evidence that the resident was notified of the outcome of her two grievances.
28 Pa. Code 201.18 (b)(1)(3)(2.1)(4) Management
28 Pa. Code 201.29 (a) Resident Rights
| | Plan of Correction - To be completed: 07/30/2024
R1 was discharged from the facility. E3, the Guest Services Director, did complete all follow up, but did not complete written documentation summary within the timeframe outlined in the Grievance Policy. Followup summary with R1was completed. E3 was educated on the Grievance Policy, and documented all follow up actions. All Department Heads were educated on the Grievance Policy and documenting follow up actions.
NHA and DON will meet with E3, who completes all grievance documentation, weekly to ensure all grievances have documented follow up and summaries, in accord with the Grievance policy for 4 weeks, and audit grievance logs for completion. Results of audits will be reviewed at QAPI.
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