§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.
§483.10(f)(6) The resident has a right to participate in family groups.
§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
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Observations:
Based on review of facility policy, resident council meeting minutes and resident and staff interviews, it was determined that the facility failed to provide evidence that Resident Council concerns were assigned to the appropriate department, facility responses to Resident Council concerns, and how the facility resolved the repetitive Resident Council concerns for three of three months (January, February, and March 2024).
Findings include:
The facility indicated they do not have a Resident Council policy.
Review of the facility policy "Grievances" dated 8/16/23, indicated the resident has the right to voice grievances with respect to treatment which has been furnished as well as that which has not been furnished. The facility actively seeks a resolution and keeps the resident appropriately apprised of its progress toward resolution.
Review of Resident Council meeting minutes for the meeting on 1/15/24, indicated the following concerns: call lights not being answered on evening and night shifts, unable to find Nurse Aides (NA), they are always on their phones, have attitudes, not setting up meal trays, and clothing items were missing.
Review of Resident Council meeting minutes for the meeting on 2/12/24, indicated the following concerns: on evening and night shifts unable to find NA's, not answering call lights, not setting up meal trays, staff standing at the desk on their phones all the time, and NA's leaving bags of linen on the floor.
Review of Resident Council meeting minutes for the meeting on 3/11/24, indicated the following concerns: NA's not answering call lights, not setting up meal trays, meals being cold, NA's standing at the desk on their phones, leaving dirty linens on the floor, that weekends are just horrible, and clothing items were missing.
Review of Grievance and Complaint Log dated February 2024, and March 2024, indicated the following:
2/12/24 - Unacceptable call light response time, and on and off the commode.
2/13/24 - Resident Council unacceptable call light response time, availability of NA's, and cold meals.
2/15/24 - Unacceptable call light response time and attitudes from NA's.
2/15/24 - Unacceptable call light response time and attitudes from NA's.
2/15/24 - Left on toilet too long by NA, call light timeliness, and attitudes from NA's.
2/15/24 - Care concerns, call light timeliness, attitudes from nursing staff.
3/2/24 - NA's not assisting with meals.
3/8/24 - Resident was in shorts on a cold day, due to no clean clothing.
3/9/24 - NA's not assisting with meals.
3/11/24 - Resident Council ongoing concern of call lights not being answered, not setting up meal trays, and meals being cold.
3/12/24 - NA's always on their phones, call light timeliness is lacking, food is always cold.
Interview on 3/15/24, at 1:45 p.m. the Nursing Home Administrator confirmed there was no evidence that Resident Council concerns were assigned to the appropriate department, facility responses to Resident Council concerns, and how the facility resolved the repetitive Resident Council concerns for three of three months (January, February, and March 2024).
28 Pa. Code 201.29(j) Resident rights.
| | Plan of Correction - To be completed: 03/25/2024
Residents who attend resident council meetings were given a facility letter indicating that their concerns were addressed and given to the appropriate department head to ensure there was a resolution of the concerns.
During resident council meetings, the facility will go over past concerns and what was done about them by the activity's director.
The activity director has been educated on going over past concerns with the residents and the findings of these concerns by the NHA.
NHA or designee will conduct an audit of all concerns throughout the facility and resident council have been addressed 3x a week for 2 weeks and then 3x a month for 2 months. Findings will be sent to QAPI.
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