§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, select policy review, resident group interview and staff interviews, it was determined that the facility failed to ensure residents were knowledgeable and had access to forms to file an anonymous grievance for four of four residents interviewed (Residents 2, 13, 27, and 37).
During the Resident Group meeting on August 13, 2019, at 11:00 AM, the four residents attending (Residents 2, 13, 27, and 37) were asked if they knew how to file a grievance/concern and they responded that they would tell someone. When theses same residents were asked as to whether they knew how to filed an anonymous concern, they appeared to be puzzled and revealed they didn't know they could do that.
Review of the facility Policies and Procedures regarding Grievances (created November 2, 2016, with no revision date) revealed on Line 2 "Resident and/or Resident Representative may file a grievance either verbally or in writing by communicating the grievance with a member of the staff." Review of Line 4. revealed "RN (Registered Nurse ) Supervisor will complete a "Concern Form", located in the nursing medication room filing cabinet."
Observation was also made on August 13, 2019, that resident rooms had plastic holders mounted on the walls in their rooms which contained a binder with some resident directed information. Review of page 8 "CONCERNS" revealed the statement "The Shook Home makes every attempt to address concerns. See the Nursing Supervisor or Social Services for assistance. Your concerns will be addressed in a timely manner.
Review of facility grievance policy or written information provided to residents provided a process for enabling residents or Resident Representative to submit an anonymous grievance/concern.
During an interview with Nursing Home Administrator (NHA) on August 14, 2019, at 2:06 PM, the NHA revealed the expectation that filing an anonymous grievance would be an option.
28 Pa. Code 201.29(i) Resident Rights
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Residents 2, 13, 27, and 37 will be educated on the process for filing an anonymous concern as contained herein.
All Residents and Resident Representatives will be educated on the process for filing an anonymous concern as contained herein.
The Director of Social Services (or designee) conducted a root cause analysis of this incident and determined that the facility failed to provide a means for residents and their representatives to file anonymous concerns.
Based on the root cause of the incident:
The Director of Social Services (or designee) will revise the facility policy regarding Grievances (created November 2, 2016) to include the process for filing anonymous concerns. This procedure will be as follows:
1. "Concern Forms" and return envelopes (self-addressed to the Director of Social Services) will be kept in the binders containing resident-directed information stored in the Resident rooms.
2. Residents and/or their Resident Representatives may complete the forms and place them in a mailbox located outside the Director of Social Services' office.
3. Residents may give the sealed envelopes to any nursing staff member to deposit them in the mailbox located outside the Director of Social Services' office if the Residents are unable to do so themselves.
4. The Director of Social Services (or designee) will check the mailbox Monday thru Friday during normal business hours. The Director of Social Services (or designee) will check the mailbox on the first business day following a weekend or holiday.
This procedure will also be added to page 8, titled "Concerns," in the binders containing resident-directed information stored in the Resident rooms.
The Director of Social Services (or designee) will educate all Registered Nurses (RNs), Licensed Practical Nurses (LPN's), and Certified Nurse Aides (CNAs) on the revised facility policy regarding Grievances (created November 2, 2016).
The Director of Social Services (or designee) will conduct an initial audit of all residents to ensure they know the process for filing an anonymous grievance.
The Director of Social Services (or designee) will then conduct a monthly audit of 25% of residents to ensure they know the process for filing an anonymous grievance.
The Director of Nursing (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.