§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 with residents and staff, review of clinical records, review of monthly resident council minutes and review of facility policy, it was determined that the facility did not ensure prompt efforts were made to resolve residents' grievances and/or concerns elated to, billing clarification, status of the activity van, request for room change and missing items for 11 of 11 residents attending resident council (Residents R10, R12, R16, R17, R38, R52, R66, R79, R90, R91 and R101) and two of 25 resident records reviewed (Resident R26 and R41).
Findings include:
Review of facility policy titled, "Grievance/Concern Management" not dated, states, "Residents/patients have the right to present concerns on behalf of themselves and /or others to the staff and/or administrator of the facility, to governmental officials or to any other person ... these rights also include the right to prompt efforts by the facility to resolve resident concerns." The same policy states, attempts to resolve concern are within 3 business days, and if unresolved within the 3-days it is reported to the Nursing Home Administrator (NHA). The policy further states the Social Service Representative maintains contact with the complainant providing updates and makes entries in the medical record under SS (Social Services) notes regarding the concern and will follow up with the reporter to confirm satisfaction with the outcome and document the resolution in the medical record.
Review of clinical records revealed Resident R26 was admitted to the facility in November 2020, alert and oriented with a primary diagnosis of heart failure. Interview with Resident R26 on November 12, 2024, at 11:00 a.m. indicated her husband became a resident at the facility (Resident R80) and both have requested to share a room together. Resident R26 said the Social Worker, Employee E25 is supposed to help me, but she never gets back to me. The last time I spoke with her was at least two weeks ago. She told me there was a lot of work involved moving residents that made me feel that the move won't happen.
During the same interview Resident R26 pointed to an orthopedic brace with an attached shoe and indicated the other shoe is missing. The resident stated, "The facility wants me to buy new shoes when they're the ones that lost it. I also haven't heard back from the Social Worker for this too!" Review of Resident R26's Social Services note from Social Worker, Employee E25 dated July 24, 2024, stated, "Resident was made aware that when an appropriate room is available, they will be placed together and to be mindful of RM (roommate) when visiting with each other and to utilize MDR (main dining room) and TV room for visits." Review of Resident R80's clinical records revealed a physician note dated July 24, 2024, stating, "While he is at this facility he wants to share a room with his wife."
Review of Resident R26's Social Services note dated September 20, 2024, noted Resident was told again that there are currently no semi-private rooms available.
Review of Resident R26's Occupational Therapy (OT) notes dated October 22, 2024, indicated Resident R26 was not able to transfer that day due to missing right shoe. OT note dated October 25, 2024, indicated Resident R26 was unable to address transfer goals until they get replacement left shoe, noted "Social Worker is looking into another option of obtaining shoes" and indicated the resident was going to be moved into bedroom with husband on Monday October 28, 2024. OT note dated November 3, 2024, stated would look into the status of shoes. OT discharge summary dated November 7, 2024, discharge recommendations stated, "Resident needs to purchase shoes." On November 14, 2024, at 2:00 p.m. surveyor requested status and/or documentation related to Resident R24's move and missing shoe and the Nursing Home Administrator indicated he was aware and would supply additional documentation but failed to submit.
Review of Resident R41's clinical record revealed the resident was admitted to the facility in September 2021 diagnosed with multiple sclerosis (an autoimmune disorder that effects the central nervous system). Interview with Resident R41 on November 12, 2024, at approximately 11:00 a.m. stated, "The [Social Worker (SW) Employee E25] said she called my insurance company because I make appointments that aren't covered and I don't show up, so they charge the facility. That's not true because I don't make my appointments, I have the nurses at the front desk make my appointments and never cancel, I have been trying to talk to the SW for at least two weeks because if they (the facility) are being charged I told the SW I want to see those bills. On November 14, 2024, at 2:00 p.m. a request for further documentation received by the Nursing Home Administrator (NHA) revealed an outpatient test done was for Resident R41 on September 27, 2024, with a remaining balance at was not charged to the resident.
On November 14, 2024, at 10:00 a.m., during a group meeting with 11 residents, all shared that the facility was not letting them know the status of the activity van. Resident R12 said they have not had the van since March. The NHA keeps telling us, "Just two more weeks, just two more weeks." Recently the NHA said it needed a battery but that was weeks ago, it shouldn't take so long!". Review of the last three months of resident council minutes revealed on September 26, 2024, residents inquired about the status of the activity van and the facility documented response was the residents were "Informed and updated" without any additional specifics. Review of resident council minutes for October noted "The resident are wondering when the van is coming back to do outing."
Interview with the NHA on November 14, 2024, at 11;00 a.m. indicated the van is still at the shop. The residents don't know this because it is not a regulation, we have a van for activities, but the van might be totaled. It was in an accident, and we might not be able to get it fixed. The NHA indicated needing to wait a few more days to see what happens before saying something to the residents.
The facility did not ensure prompt efforts were made to resolve grievances and their concerns
28 Pa. Code 201.29(a)(i) Resident rights
| | Plan of Correction - To be completed: 12/26/2024
Facility provided semi-private room to residents R26 and R80. Resident R41 wants to make her appointments by herself for which facility educated resident R41 regarding appointments will be made by the facility staff and facility will provide monthly account statement to resident R41 for her concern regarding any charges. Facility ordered R26 shoes as requested. NHA discussed facility van status with residents in resident council meeting and informed residents that resident van is no longer usable. IDT will audit the last 30 days of grievances to ensure prompt resolution. IDT will educate the social services director, nursing administration and compliance officer on grievance policy, grievance officer and procedure of filing grievances. IDT will complete thorough investigations and ensure that all grievances are completed within 5 working days, unless investigation warrants additional time. Facility will audit all filed grievances weekly x4 and monthly x2 for completion and accuracy. Results of audit will be reviewed at the facility QAPI meeting monthly x 3.
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