§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 a review of facility policy, clinical records, grievance logs, and Concern Forms it was determined that the facility failed to perform a thorough and complete investigation for grievances that were submitted in the facility related to resident care and call bell times for three of three residents (Resident R1, R2, and R3).
Findings include:
Review of facility policy, "Abuse, Neglect and Misappropriation," dated 4/18/24, indicated that the facility will provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents.
Definition of Neglect: the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid harm, pain, mental anguish, or emotional distress.
Review of Resident R1's clinical record indicated the resident was admitted 8/2/21.
Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 5/11/43, indicated he had diagnoses that included hypertension (condition impacting blood circulation through the heart related to poor pressure), anxiety, and depression.
Review of Resident R1's care plan dated 8/5/21, indicated the resident had deficits in self-care and requires assistance. It was indicated the resident is dependent for toileting hygiene and requires two or more persons for assistance.
During a review of Concern Form dated 5/31/24, at 1:00 p.m. indicated that the facility received a Concern Form for Resident R1. Description of concern was the resident reported that the nurse ' s aide did not put her to bed after therapy. Stated she was in her chair for a long period of time, and she was sore. Resident R1 reported that she was not put back to bed until the next shift. Actions taken to resolve the concern was the facility had a conversation with resident and asked psychiatry (mental health specialty) and psychology (mental health specialty) to see resident. Advised resident to notify supervisor when any issues arise at the time. The Concern Form was also missing Administrators signature. The facility failed to complete a thorough investigation into Resident R1 ' s grievance for neglect. Facility failed to provide documentation of resident and staff statements/interviews, actions taken to prevent neglect from happening again, and failed to notify proper agencies of the allegation.
During a review of Concern Form dated 6/4/24, at 1:40 p.m. indicated that facility received a Concern Form for Resident R1. Description of concern was that call bell is not being answered. Feels staff do not know how to use a sliding board for transfers. Actions taken to resolve the concern was that resident was discontinued from therapy on 5/31/24. Therapy did staff education. Will need to re-educate. The Concern Form was missing who was notified of grievance and was also missing Administrators signature. The facility failed to complete a thorough investigation into Resident R1's grievance for neglect. Facility failed to provide documentation of resident and staff statements/interviews, actions taken to prevent neglect from happening again, and failed to notify proper agencies of the allegation.
During an interview with Resident R1 on 6/6/24, at 1:06 p.m. resident stated, "I went to lunch, I had to wait for next shift. I didn't get into bed until next shift, and I needed to be changed. I was stuck in this chair the whole time. I was miserable."
Review of Resident R2's clinical record indicated the resident was admitted on 3/24/23.
Review of Resident R2's MDS dated 5/6/24, indicated she had diagnoses that included heart failure (a progressive heart disease affecting the pumping action of the heart impacting circulation and causing shortness of breath), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), and hypertension.
During a review of Resident R2's care plan dated 3/27/23, indicated the resident had deficits in self-care and requires assistance. It was indicated the resident requires partial/moderate assistance for transfers and requires assistance for set up and clean up for toileting hygiene.
During a review of Concern Form dated 5/30/24, at 12:00 p.m. indicated that facility received a Concern Form for Resident R2. Description of concern was that resident activated her call bell and a staff member came into her room, turned her light off, failed to assist resident and walked back out of room. Resident R2 turned her call bell on again and no one answered it for three to four hours later. Actions taken to resolve the concern was that no one matching description was on duty that evening. The Concern Form failed to indicate who was made aware of the grievance and was missing the Administrator ' s signature. The facility failed to complete a thorough investigation into Resident R2's grievance for neglect. A review of Resident R2's concern form failed to provide documentation of investigation including resident and staff statements/interviews, actions taken to prevent neglect from happening again, and failed to notify proper agencies of the allegation.
During a review of Resident R2's clinical record on 6/6/24, at 11:35 p.m. indicated Resident R2 was admitted to the hospital. Resident R2 was unavailable for an interview.
Review of Resident R3's clinical record indicated the resident was admitted on 5/15/24.
Review of Resident R3's MDS dated 5/22/24, indicated he had diagnoses that included hypertension, depression, and thyroid disorder (medical condition that keeps your thyroid from making the right amount of hormones.)
During a review of Concern Form dated 5/16/24, at 2:00 p.m. indicated that facility received a Concern Form for Resident R3. Description of concern was that resident reported she was told at lunch time that she had to wait until the next shift to be changed. Actions taken to resolve the concern was the aide was no longer here. The facility failed to complete a thorough investigation into Resident R3 ' s grievance for neglect. Review of Resident R3's concern form failed to provide documentation of investigation including resident and staff statements/interviews, actions taken to prevent neglect from happening again, and failed to notify proper agencies of the allegation.
During an interview with Resident R3 on 6/6/24, at 1:05 p.m. resident stated, "Sometimes if they are busy or if they are in changing somebody it can take longer. One day someone turned my light off and left. Someone else came in to help me then. I needed changed. I urinated in my brief".
During an interview on 6/6/24, at 5:00 p.m. the Nursing Home Administrator confirmed that the facility failed to perform a thorough and complete investigation for grievances that were submitted in the facility related to resident care and call bell times for three of three residents (Resident R1, R2, and R3).
28 Pa. Code: 207.2(a) Administrator's responsibility.
28 Pa. Code: 211.12(d)(1)(5) Nursing services
28 Pa Code: 201.29 (I)(o) Resident rights.
| | Plan of Correction - To be completed: 07/08/2024
Preparation and/or execution of this
plan of correction does not
constitute admission or agreement
by the provider of truth of the facts
alleged or conclusion set forth in the
statement of deficiencies. The plan
of correction is prepared and/or
executed solely because it is
required by the provisions of federal
and state law.
Residents R1, R2 and R3 grievances were elevated thru ERS as allegations of neglect. Interviews and statements obtained from residents and staff relating to grievance. Notifications made to proper agencies of allegations.
Like residents were identified by location. Residents on the same hall/unit were interviewed by social service, un-interviewable residents had skin assessments completed by nursing staff: based on nature of allegation.
Education provided to administrator, don and social services by regional director of clinical operations on resident grievance policy.
Social services will review new grievances at the Interdisciplinary Team (IDT) during morning meetings 5 days per week for 3 weeks. Grievances will be added to the Grievance Log for tracking of compliance. The Administrator will review the Grievance Log and investigations weekly x3 to ensure ongoing and maintained compliance. All concerns classified as neglect by IDT will be reported thru ERS and proper agencies. Audits will be reported to the QAPI committee for further review and consideration.
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