§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 a review of grievances lodged with the facility and select facility policy and resident and staff interviews it was determined that the facility failed to demonstrate timely and adequate efforts to resolve resident grievances for two residents out of 16 sampled. (Resident 2 and 11)
Findings include:
A review of facility policy entitled "Resident and Family Grievances" revealed the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. The staff will forward the grievance form to the grievance official as soon as practicable. The grievance official takes steps to resolve the grievance and record information about the grievance and those actions on the grievance form. In accordance with the residents right to retain a written decision regarding his or her grievance, the grievance official will issue a written decision of the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum, the date the grievance was received, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concerns, a statement to whether the grievance was confirmed or not confirmed, any corrective action taken by the facility as a result of the grievance, and the date the written decision was issued.
A review of a grievance lodged by Resident 2 dated January 28, 2024, which was requested for review during the recent survey at the facility, completed on February 6, 2024, but not provided at the time of request, revealed that the resident expressed a concern with staff not answering call bells in a timely manner and that the nurse aides sit in a back room on their phones. The grievance indicated that the resident felt that the facility should restrict phone usage to break times so residents are taken care of.
According to the grievance form, the facility noted that the resident's complaint was resolved on February 1, 2024. However, there was no documented evidence that the resident had been informed of the outcome of the grievance. The resident did not sign off that he received the facility's response or was aware of the actions taken by the facility to resolve his grievance. There was no documented evidence that the facility educated staff on use of their personal cell phones while on duty.
An interview with Resident 2 on February 28, 2024, at 10:15 AM revealed that the resident stated that his concerns were not yet resolved. The resident stated the wait times for staff to respond to call bells and provide requested care, remains a problem. The resident stated that it still takes up to 45 minutes for staff to respond to his call bell and meet his needs for assistance. The resident confirmed that the facility did not provide him written details of the outcome of his grievance and no one had asked him if he was satisfied with the outcome or if he still had concerns.
A review of a grievance filed on behalf of Resident 11 dated January 29, 2024, which was also requested for review during the survey ending February 6, 2024, but not provided upon request at that time, revealed that the resident's daughter had concerns with a small box cutter type knife found in her mother's bed. The resident's daughter questioned how the small knife ended up in her mother's bed and was concerned that her mother could have been hurt.
According to the grievance form, this complaint was resolved on February 2, 2024. However, there was no indication that the resident's daughter or the resident had been informed of the outcome, as the area of the form indicating notification of the representative was blank. Neither the resident nor the resident's daughter signed the form to acknowledge their receipt of the facility's response to the complaint and awareness of the actions taken to resolve the complaint.
An interview with Resident 11 on February 28, 2024, at approximately 10:30 AM revealed the resident was asked if she recalled the incident when a small blade was found in the resident's bed. The resident shook her head "yes." When asked if anyone came back to speak with her about how the blade ended up in her bed or what the facility did to correct these concerns, the resident shook her head "no."
During an interview with the Nursing Home Administrator (NHA) on February 28, 2023, at approximately 4:00 PM, the NHA was unable to provide documented evidence that the facility followed-up, in a timely manner, with the residents and/or their representatives to inform them of the outcome of their grievance and ascertain the effectiveness of the facility's efforts in resolving their complaints.
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 201.29 (a) Resident rights
| | Plan of Correction - To be completed: 03/15/2024
F0585 (Grievances)
Resident 2, and resident 11 grievances were reviewed to assure resolution.
Social Service/designee followed up the residents / resident representative on the outcome of the grievances.
The facility has determined that all residents could be potentially affected.
The staff educator/designee will provide education to the grievance official, Administrator/DON/department heads on the facility grievance policy and procedures and the importance of adequately making efforts to resolve grievances timely.
Grievances will be reviewed in stand up meeting for completion.
The NHA/designee will review grievance forms to assure that the facility provided evidence of timely follow up to residents/representatives the outcome related to the grievances Audits will be done weekly for 4 weeks, then monthly for 2 months or until compliance is sustained. Date of Compliance 3.15.2024
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