§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 review of facility policy, and interviews with residents and staff, it was determined that the facility failed to establish grievance policies and procedures that include the right to file a grievance for 2 of 13 residents reviewed.
Findings include:
Review of facility policy titled "Grievance Policy" revealed "each 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 .
Interview with Resident R2 on March 15, 2024, at 10:41 a.m. revealed that call bell response being a problem, last weekend it took two hours to get a response. Resident R2 did notify administration and he reported that " I'll take care of it".
Interview with Resident R1 on March 15, 2024, at 10:43 a.m. revealed that call bell response being a problem and last weekend it took couple of hours for her call bell to be answered. The call bell response is the worse during the shift form 3PM-11PM, 11PM-7AM and weekends. Resident R1 also complained about food taste being horrible and that no menus are provided to make preference for meals. Resident R1 did inform the nurse supervisor and administration and was told by the administrator "I'll take care of it".
During a tour with Unit Manager, Employee E3, on March 15, 2024, at 11:48 a.m. Resident R13 filed a grievance with the Unit Manager, Employee E3 as the Resident's R13's call bell response was 1.5 hours. Employee E3 reported that she had a meeting with her staff to address the response time, but it was not documented as a grievance, nor was it communicated to the Resident R13 the resolution of the outcome of his grievances.
Three months from December 2023, January -March 2024 were reviewed and the above grievances were not documented nor reflected in the grievance log for those dates. Three grievances were pulled that had a call bell, dietary and care issues which the forms reveled that residents or resident representatives were not contacted to share the resolution of the grievance.
Interview with the Nursing Home Administrator on March 15, 2024, at 2:43 p.m. confirmed that the results of the grievances were not communicated to residents or resident representatives. The Nursing Home Administrator shared that they implemented call bell audit program of doing audits three times a week as on the last Resident Council meeting notes which occurred on February 29, 2024, residents expressed a concern with call bell of lack of response.
28 Pa. Code 201.18(b)(3) Management
| | Plan of Correction - To be completed: 04/17/2024
1- A grievance form was completed for R1 regarding call bells, taste of food and lack of menus to indicate preference. A grievance form was completed for R2 regarding call bells. A grievance form was completed for R13 regarding call bells.
2-Grievances from December 2023 thru March 2024 will be reviewed and completed per facility policy
3-Current staff were re-educated on facility's grievance policy and process
4-NHA or designee will audit grievances weekly to ensure proper notifications/resolutions have been made.
NHA or designee will complete 3 random call bell audits weekly x 2 months.
Results will be reviewed during facility's monthly QAPI meeting.
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