§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 a review of facility policy, the minutes from Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined that the facility failed to demonstrate sufficient efforts towards prompt resolution of continued resident complaints voiced during Resident Council meetings including those voiced by seven residents (Residents A4, A5, A6, A7, A8, A9, A10 and A11 ).
The findings include:
A review of facility policy for "grievance program" reviewed by the facility April 2023 revealed the process that upon receipt of a grievance, the grievance officer will designate an administrative staff member to investigate the concern. The goal of the facility is to investigate is to investigate the within 7 days. The administrative staff will determine what corrective actions. The resident or person filing the grievance will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems and document on the appropriate concern form.
A review of the minutes from the Resident Council meeting dated January 11, 2024, revealed that 22 residents attended the meeting. The residents reported that the council reviewed ongoing concerns and that facility staff reminded the residents that during meal tray pass that staff will answer call bells as soon as the meal trays are passed. The facility asked the residents to be mindful of when the meal is, and try to get their care needs done before meals.
A review of resident concern forms filed during the Resident Council meeting dated January 11, 2024, reveled that Residents A4, A5, A6 and A7 voiced concerns that "staff are going down the back stairs and smoking, Residents are able to smell staff smoking." The facility noted that the concern was addressed, and completed, dated Janaury 18, 2024, noting "zero signs and symptoms of smoking in the stairwell. Will monitor."
An additional concern form was filed on January 11, 2024, indicated that Residents A4, A5, A8, A7, A6, A11, A9 and A10 voiced complaints that, "staff are more concerned about socializing with each other than doing their jobs after facility administration staff leave for the day. Staff telling you to go to their bed, go to your room, you don't belong here, you are in the wrong hallway." The facility indicated that concern was addressed, and noted the grievance resolution was completed, January 18, 2024, noting the resolution as "education completed with staff."
There was no documented evidence at the time of the survey ending February 15, 2024, that any education was provided to the facility staff as a means to resolve the residents' complaints filed January 11, 2024, as the facility noted on the grievance form.
A review of a resident concern forms filed during the resident council meeting dated January 11, 2024 reveled that Residents A4 and A9 also stated that, "during the middle of the night, approximately between 2 AM and 3 AM staff is extremely loud. Difficult for residents to sleep." The facility indicated that this complaint was addressed and resolution completed, dated Janaury 24, 2024, and noted "screaming/loudness is a resident with behaviors."
During an interviw February 15, 2024 at approximately 12:30 PM Resident A9 stated that it takes nursing staff up to one hour to respond to her call bell when she rings for assistance. She stated that staff will respond to the call bell, turn the bell off and not return to provide care in a timely manner. She stated that this problem occurs daily. She stated that she had informed licensed nursing staff of the issue and it is still happening.
The facility was unable to provide evidence at the time of the survey ending February 15, 2024, that the facility had determined if the residents' felt that their complaints or grievances had been resolved through any efforts taken by the facility in response to the residents concerns with untimely call bell response times, staff behavior and treatment of residents, and the disruptive behaviors of other residents.
During an interview with the Nursing Home Administrator (NHA) on February 15, 2024, at 3 PM, the NHA confirmed that the facility was unable to demonstrate that reasonable efforts were taken to ascertain the effectiveness of the facility's efforts in resolving the residents ongoing complaints regarding untimely staff call bell response times, staff behavior and conduct, and the disruptive behaviors of other residents.
28 Pa. Code 201.18 (e)(1)(2) Management
28 Pa. Code 201.29 (c) Resident rights
| | Plan of Correction - To be completed: 03/19/2024
Evidence will be provided that Residents A4, A5, A6, A7 concern related smelling smoke in the stairwell has been resolved. Evidence will be provided that Residents A4, A5, A8, A7, A6, A11, A9, and A10 concern related to staff behavior and treatment on second shift has been resolved. Evidence will be provided that Residents A4 and A9 concern related to disruptive behaviors of other residents at night has been resolved. Evidence will be provided that Resident A9 call bell response concern has been resolved.
February grievances will be reviewed to validate resolution.
Interdisciplinary Team will be educated on the Grievance Policy and call bell response. Nursing staff will be educated on the Grievance Policy and call bell response.
NHA or designee will audit 5 concern forms weekly for 12 weeks to validate evidence of timely resolution. DON or designee will audit call bell response 5 times weekly for 12 weeks to validate timely response and report results to QAPI Committee meetings for review.
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