§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, clinical records, and facility grievance forms, as well as staff interviews, it was determined that the facility's policy failed to indicate a reasonable expected time frame for completing the review of the grievances, and that the facility failed to make prompt efforts to resolve a grievance by not having documented evidence of the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the resident's concerns, or any corrective action taken or to be taken by the facility as a result of the grievance for eight of 11 residents reviewed (Residents 4 through 11).
Findings include:
The facility's grievance policy, dated February 22, 2024, indicated that the nursing home administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer (e.g. Social Services). Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. The investigation and report will include, as applicable, the date and time of the alleged incident, the circumstances surrounding the alleged incident, the location of the incident, the names of any witnesses and their accounts of the alleged incident, the resident's account of the alleged incident, accounts of any other individuals involved, and recommendations for corrective action. The grievance officer will record and maintain all grievances and complaints on the "Resident Grievance Complaint Log." The following information will be recorded and maintained in the log: The date the grievance/complaint was received, the name and room number of the resident filing the grievance/complaint, the name and relationship of the person filing the grievance/complaint on behalf of the resident, the date the alleged incident took place, the names of the person(s) investigating the incident, the date the resident or interested party was informed of the findings, and the disposition of the grievance. The "Resident Grievance/Compliant Investigation Report Form" will be filed with the nursing home administrator/designee timely. The resident or person acting on behalf of the resident will be informed of the findings of the investigation, as well as any corrective actions recommended.
However, the facility's grievance policy did not indicate a reasonable expected time frame for completing the review of the grievances.
The facility's Grievance, Concern, Complaint Log, dated April 2024, revealed:
On April 18, 2024, Resident 4 and Resident 5 submitted a concern that they do not get enough to eat.
On April 18, 2024, Resident 6 submitted a concern that she does not like the food and does not get what she orders.
On April 18, 2024, Resident 7 submitted a concern that she does not get what she orders.
On April 26, 2024, Resident 8's daughter submitted a concern that the food is cold and nasty.
On April 29, 2024, staff submitted a concern for Resident 9 that he requires honey thick liquids, and that he received thin liquids on his breakfast tray.
On April 29, 2024, staff submitted a concern for Resident 10 that she requires nectar thick liquids, and that she received honey thick liquids on her breakfast tray.
On April 29, 2024, Resident 11's niece submitted a concern that she continues to receive bread of multiple types on her meal trays.
As of May 14, 2024, there was no documented evidence that the facility made prompt efforts to investigate and resolve the above grievance/complaints.
Interview with the Nursing Home Administrator on May 14, 2024, at 12:45 p.m. confirmed that the facility's grievance policy did not indicate a reasonable expected time frame for completing the review of the grievances, and that there was no documented evidence that the facility made prompt efforts to investigate and resolve grievances for Residents 4 through 11.
28 Pa. Code 201.29(i) Resident Rights.
| | Plan of Correction - To be completed: 06/10/2024
Administrator provided retraining to Grievance Officer and dietary manager.
Administrator or designee will follow up with patients #4-#11 by 6/4/24 to ensure their grievance has been addressed.
Grievance Officer to complete new policy and new "Resident Grievance/Complaint Investigation Report Form" by 6/7/2024. IDT team to review and adopt new policy by 6/7/2024.
New policy and "Resident Grievance/Complaint Investigation Report Form" to include, date grievance form received by Grievance Officer and date Grievance Officer forwards to department manager to initiate investigation. Investigation to be completed within 7 business days after Grievance Officer receives initial grievance. The time indicated may be less than seven business days as determined by the Grievance Officer or Interdisciplinary Team (IDT team) as it relates to the nature of the concern.
Dietary manager completed ticket system audit to ensure tickets, diet and hydration status correct for all patients.
Administrator or designee to audit "Resident Grievance Complaint Log" twice weekly for two weeks, once weekly for two weeks to ensure timely completion of concerns. Administrator to follow up within 24 hours on any grievances not completed within the first five days after being forwarded to the assigned manager to initiate investigation.
Dietary manager or designee to complete ticket system audit twice weekly for two weeks, once weekly for two weeks.
Results of audits will be presented to the Administrator by the Grievance Officer at monthly quality assurance and performance improvement meeting for a period of 3 months.
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