§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 policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve the grievances of residents and/or their legal representatives for one of five residents reviewed (Resident 5).
Findings include:
The facility's policy regarding filing grievance and complaints, dated February 2022, indicated that all grievances and complaints filed with the facility were to be considered, the allegations would be investigated, and a report would be submitted to the administer within five days. The Nursing Home Administrator would review the findings with the Grievance Office to determine what corrective action, if any, and would take immediate action to prevent potential violations of resident rights.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 27, 2022, revealed that the resident was cognitively intact, was understood, could understand, and required limited assistance of one for eating.
A tour of the kitchen's dry storage area on June 29, 2022, at 8:27 a.m., revealed 13 racks of fresh bread products (sliced loaves, hamburger and hot dog rolls) that had a handwritten sign that said, "Check break for mold before serving."
An interview with the Dietary Director on June 29, 2022, at 11:34 a.m., revealed that Resident 5 received moldy bread on his meal trays twice. The first time was over a month ago, and then again on June 23, 2022. After the first occurrence she filed an orange grievance form with management. The Dietary Director further explained that she provided education to staff and planned to monitor breads for mold. The Dietary Director was off during the second incident and did not file another grievance form.
There was no documented evidence that grievances were filed on behalf of Resident 5 related to his concerns about moldy food.
During an interview with Resident 5 on June 29, 2022, at 12:20 p.m. he indicated that he was served a moldy dinner roll in a plastic sealed bag on May 28, 2022. At that time he communicated his concern to administration, the Director of Nursing, and kitchen staff. Resident 5 indicated that the kitchen apologized, but he felt like his concern was not taken seriously. Following the incident the Nursing Home Administrator came to talk to him, but his roommate was receiving care, and the Nursing Home Administrator did not return to discuss the concern. The second incident occurred on June 23, 2022, when Resident 5 was served a ham and cheese sandwich on bread with mold on the crust, and he was very upset. Resident 5 was told he would sign a paper, but that did not occur. Resident 5 had no resolution regarding moldy food.
Interview with the Regional Director of Clinical Operations on June 29, 2022, at 1:02 p.m. revealed that there was no documented evidence that any grievance was filed after April 11, 2022, or any grievances related to Resident 5's expressed concerns about being served moldy food. Furthermore, after talking to the dietary staff an initial grievance was filed, but there was no documented evidence of the grievance form, investigation, or staff education. There was also no documented evidence that a grievance was filed following the second incident of moldy food on June 23, 2022.
Interview with the Director of Nursing on June 29, 2022, at 2:06 p.m. confirmed that when any concerns are verbalized by residents, the concerns should be investigated and resolved following the facility's policy.
28 Pa. Code 201.29(i) Resident rights.
| | Plan of Correction - To be completed: 08/02/2022
R5 grievance was entered into electronic grievance system. Dietary staff was re-educated on visual inspection of bread prior to serving.
All bread was check in house to ensure no other moldy bread present.
follow up was completed by dietary manager with resident and ongoing plan.
Grievance process will be reviewed with residents at resident council. Any reported items will be logged by the administrator/ designee into electronic grievance system. Follow up will be completed by social service director or designee and reported to resident and person filing the grievance
Interdisciplinary team will be in-serviced by Director of Clinical Operations on grievance policy procedure.
Audits will be completed weekly x2, and monthly x2 to ensure grievances are logged and completed timely.
Findings of audits will be submitted to the monthly quality assurance committee for review.
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