Wayne County Nursing Home
March 23, 2017 Complaint Survey

Standard Health Citations

FF10 483.10(j)(2)-(4):RIGHT TO PROMPT EFFORTS TO RESOLVE GRIEVANCES

REGULATION: (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. (j)(3) The facility must make information on how to file a grievance or complaint available to the resident. (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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 23, 2017
Corrected date: May 23, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 290) completed on 3/23/17, it was determined that for two (Residents #1 and #3) of three residents reviewed for grievances, the facility did not ensure that each resident's grievance was resolved in a prompt manner. The issues were related to complaints of a resident's frequent yelling and loud behaviors. This is evidenced by the following: Resident #4 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/12/16, revealed that Resident #4's cognition is moderately impaired. A Quality Concern Form, dated 12/23/16 to 1/2/17 completed by a family member for Resident #1, revealed that Resident #4 was swearing and yelling while residents were trying to eat or enjoy the living room area. The family member spoke with the Social Worker (SW) and was told to give it some time. A Quality Concern Form, dated 1/7/17 and completed by a family member for Resident #1, revealed that Resident #4 calls her and Resident #1 names and frequently swears at both of them. The family member spoke with the SW twice and wants to speak to the Administrator because nothing has been done. Review of the progress notes, from 1/23/17 through 3/20/17, revealed that the resident has been calling other residents names and swearing. Resident #1 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/26/17, revealed that the resident's cognition is moderately impaired. Resident #3 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/20/17, revealed that the resident is cognitively intact. The Resident Council (RC) meeting minutes for 3/3/17 documented that Resident #3 voiced concerns regarding Resident #4's shouting, yelling, and being up all night. The Director of Social Work (DSW) stated that staff are aware and working to make life better for the residents. It is noted that the DSW would check with the nursing supervisors to see if Resident #4 can be taken to another area if she is having a bad day to help the situation. Interviews conducted on 3/3/17 included the following: a. At 12:30 p.m., Resident #1's family member stated that when she met with administration about issues related to verbal outbursts by Resident #4, she was advised that no changes would be made. b. At 12:40 p.m., Resident #1 stated that Resident #4's outbursts are upsetting, depending on how long it lasts, and he is always wondering if Resident #4 is going to swear. Resident #1 stated that this occurs two to three times a week during sleep hours and this wakes him up. c. At 1:00 p.m., Resident #3 stated that last Friday and Sunday nights, Resident #4 kept her awake by hollering, cursing, and using foul language. Resident #3 stated that she got some sleep, but not a lot. When she has company, Resident #4 hollers and curses at the company, and this has been going on since (MONTH) (YEAR). Resident #3 stated that she has spoken to the Administrator and Director of Nursing but receives no response. Resident #3 stated that she filed a formal grievance and a statement was taken by the Social Worker (SW). Resident #3 said the SW told her that Resident #4 has rights too. d. At 1:30 p.m., the Resident Council President (RCP) stated that Resident #4 is awful and her language is terrible. The RCP added that this issue has not come up at the RC meetings, but she has seen Resident #4 being transported and she uses four letter words. e. At 1:35 p.m., the SW stated that Resident #3 filed a grievance about Resident #4 and talked to her about her concerns. She said the resident did not actually file the grievance with her. The SW stated she told Resident #3 that they would look into what they could do. The SW said that Resident #4 was moved quickly during Christmas and there was not a lot of notice. Interviews conducted on 3/23/17 included the following: a. At 10:50 a.m., the DSW stated that she attended the RC meeting on 3/3/17 and referred concerns about Resident #4 to the SW on the unit. b. At 11:05 a.m., the Nurse Manager (NM) stated that Resident #4 was admitted in (MONTH) (YEAR), and within a short time her behaviors manifested. The NM stated that the resident shares the bathroom with Resident #3. She said Resident #4 was going into Resident #3's room through the bathroom. The NM stated that she locked the bathroom door on Resident #3's side and assumed that this took care of the matter, but did not ask Resident #3 if that was the case. c. At 11:50 a.m., Resident #3 stated that there have been no improvements, Resident #4 wakes her up out of a sound sleep, and this occurs often. Resident #3 stated that Resident #4 uses vulgar language and says inappropriate things to her husband. Resident #3 said that she never sees staff do anything about these incidents. She said that staff might talk to Resident #4, but that does not do any good. Resident #3 stated that she spoke with the NM and was told they are doing what they can. She said the SW and DSW both said that Resident #4 has rights too. Resident #3 said this has been going on for three months. Resident #3 said they adjust Resident #4's medications but there are no improvements. Resident #3 said that they locked her bathroom door (adjoins with Resident #4's room) but Resident #4 still gets into her personal items in the bathroom. Resident #3 said that the NM never returned to inquire if things had improved. Resident #3 stated that she brought the issue up at the RC meeting in March, but nothing has changed and she was told that Resident #4 has rights too. d. At 12:10 p.m., the Compliance Officer stated that Resident #4 is not removed from the situation during outbursts because there is no place to take her when she has behaviors. The facility Handbook for Residents and Families, revised 11/29/16, includes use of a Quality Concern and Comments Form to raise concerns. The handbook indicates that the concerns or complaints should be provided either verbally or in writing as soon as possible so that the concern may be addressed promptly. (10 NYCRR 415.3(a)(1))

Plan of Correction: ApprovedApril 13, 2017

a) For Resident #1, the roommate with behaviors that was identified in the quality concerns was moved on (MONTH) 10, (YEAR), once an appropriate bed was available. Resident #1 was interviewed on (MONTH) 13, (YEAR) and reported no further concerns about Resident #4 and stated he has seen improvements with Resident #4 over the last few days. A follow-up interview with Resident #1 will be conducted in a week.
Resident #3 was interviewed on (MONTH) 13, (YEAR) and stated she understands why Resident#4 might have had those behaviors. Compliance officer verified the grievance process with Resident#3 who acknowledged her understanding about the process and stated going forward she would report her concerns using the grievance process. Resident #3 stated she has seen slight improvements in the residents? behavior and hopes some of these new interventions will help Resident #4. A follow-up interview with the Resident #3 will be conducted in a week.
Resident #4, behavioral plan updated on 3/6/2017; facility and NP participated and presented Resident #4 as a case study in the ?Geriatric Mental Health TeleECHO Clinic? with the University of Rochester on 4/6/2017 for their suggestions about behavioral and medication management. Follow-up presentation with the TeleECHO Clinic after implementation of their suggestions will be conducted in one month. 4/14/2017
b) Social work department will conduct a facility wide audit with a questionnaire about resident?s knowledge about the grievance process and will respond promptly to their findings. All residents and families will receive tips for advocating handout and Department of Health brochures with advocacy information. 5/12/2017
c) All staff will be in-serviced on resident?s rights and the grievance process. 5/23/2017
d) Compliance Officer will conduct a weekly audit on all the quality concerns that were submitted to make sure they were resolved in a timely manner. Results of the audit will be reported at quarterly QA.
e) Responsible staff: Compliance Officer