§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.
|
Observations:
Based on review of policies, resident council meeting minutes, and facility grievance/complaint logs, as well as staff interviews, it was determined that the facility failed to follow its grievance policies regarding maintaining a log of all grievances received and failed to ensure that grievances were responded to in a timely manner for one of seven residents reviewed (Resident 4), and failed to include 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 one of seven residents reviewed (Resident 7).
Findings include:
The facility's policy regarding grievances/complaints, dated February 28, 2024, indicated that upon receipt of the grievance/concern, the grievance/concern form will be initiated by the staff member receiving the concern and documented on the grievance/concern log. The department manager will contact the person filing the grievance to acknowledge receipt, investigate the grievance, take corrective actions if needed, and notify the person filing the grievance of resolution within 72 hours.
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 2, 2024, revealed that the resident was alert and oriented and able to make her needs known.
Resident Council Meeting Minutes, dated February 16, 2024, revealed that Resident 4 presented a concern with the lack of staff to get residents into bed at night. The resident indicated that she addressed it with the Director of Nursing.
The facility's grievance/complaint logs, dated January 1, 2024, through March 20, 2024, revealed no documented evidence that Resident 4's concern regarding the lack of staff to get residents into bed at night was listed on the facility's grievance/complaint log and/or that the concern was investigated.
Interview with the Director of Nursing on March 27, 2024, at 1:55 p.m. revealed that an official grievance form was not completed regarding Resident 4's concern regarding the lack of staff to get residents into bed at night. She indicated that when she came in the next morning, she saw Resident 4, who was still upset, so she talked to her and the resident told her that she was upset that the staff does not like her. When she asked the resident why she felt that way, the resident told her it was because staff would not put her to bed that evening when she wanted to go to bed. The Director of Nursing confirmed that she did not complete a further investigation into the concerns of the resident at that time.
A grievance form for Resident 7, dated March 5, 2024, revealed that the resident presented a concern regarding long call bell times at 3:00 a.m. and not getting his pain medications.
There was no documented evidence that Resident 7's complaint/grievance was thoroughly investigated, including interviews and/or written statements from the staff who worked during the shift in question, and whether the resident was receiving his pain medications as ordered. There was also no documented evidence of a summary of the findings or conclusion regarding the resident's concerns or corrective actions taken or to be taken by the facility because of the grievance.
Interview with the Nursing Home Administrator on March 27, 2024, at 3:50 p.m. confirmed that there was no documented evidence that Resident 7's grievance included interviews with staff regarding the mentioned concerns and no summary of the findings or corrective actions taken or to be taken by the facility.
28 Pa. Code 201.29(c.3)(4) Resident rights.
| | Plan of Correction - To be completed: 05/22/2024
Resident 4 provided education regarding her option to voice concerns and file a grievance at any time. Resident 7 is no longer a resident in the facility.
Grievances in the last 30 days were reviewed by the Nursing Home Administrator (NHA) to ensure proper completion and follow through on concerns.
The NHA reeducated the Department Managers on the facility's grievance guidelines.
The Social Services Director/ designee to conduct Quality Improvement (QI) monitoring to ensure ongoing efforts to resolve grievances. Monitor conducted via weekly grievance reviews times 4 weeks X 4 weeks, biweekly X 1 months, then monthly as needed. Findings reported to the Quality Improvement Performance Improvement committee and updated as indicated. Quality monitoring schedule modified based on findings.
|
|
