§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.
Based on a review of facility policy, resident council minutes and staff interview, it was determined that the facility failed to make certain that grievances from Resident Council were addressed for five of eight months (May, June, July, September and November 2019)
The facility policy " Grievances, Resident" dated 3/19/19, indicated that the facility will do its best to respond to the resident's issue/concern within 24 hours after a thorough investigation is conducted. The resident (or resident representative) will receive notification of the outcome. A resident ( or resdient representative) with a problem should express it as soon as possible after it occurs.
During a review of Resident Council Minutes dated 5/30/19, 6/28/19, 7/29/19, 9/30/19 and 11/22/19, there were four concerns that calls bells were too long, a room needed cleaned and food orders aren't correct.
Review of the Resident Council Minutes dated 5/30/19, 6/28/19, 7/29/19, 9/30/19 and 11/22/19, revealed that the resident council concerns were not addressed.
During an interview on 12/12/19, at 1:00 p.m.. with Nursing Home Administrator Employee confirmed that there was no documentation that the resident concerns had been investigated and that the resident council concerns were not included in the facility grievance process.
28. Pa Code: 201.18(e)(4) Management.
28. Pa Code: 201.29(i) Resident rights
| ||Plan of Correction - To be completed: 01/21/2020|
1. Resident council minutes will now include follow up documentation on identified resident council concerns. The resident council concerns will also be documented on a facility grievance form.
2. Current patients have the potential to be affected. The facility will hold a resident council meeting to identify any resident council concerns. The resident council minutes which had concerns with call bell response time, resident room needing to be cleaned and a meal order not correct as identified during survey will be reviewed with the current patients to determine if these areas remain a concern with the new short term patients. Any new or old reported concerns will be documented on a grievance form and follow up will be documented on the resident council minutes.
3. The nursing home administrator will educate the department managers on the 585 regulation and the facility's grievance policy and documentation of follow up for each grievance.
4. The Administrator will review resident council minutes monthly to validate grievances along with corresponding follow up documentation was completed for each concern identified in resident council. This audit will be completed monthly for three months and then randomly thereafter. Results of this audit will be communicated at the Quality Assessment and Assurance Committee meetings