cms_AK: 22
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 22 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 585 | F | 0 | 1 | 0OWF11 | Based on observation, interview, and policy review, the facility failed to: 1) follow the grievance policy on patient care issues, 2) clearly inform residents and/or their families of the process for filing an anonymous grievance, and 3) provide correct information to contact external agencies. This failed practice had the potential to affect all residents of the facility, based on a census of 21, to deny their right to have their grievances investigated with the potential to compromise the quality of care provided by the facility. Findings: An observation on 8/19/19 at 2:54 pm, revealed no grievance box or forms were visible in the common areas. During an interview on 8/21/19 at 11:06 am with the Resident Council, Resident #'s 3, 4, 10, 12, 15, and 174 did not know who the Grievance Officer (GO) was, or where to find the contact information. Resident #16 knew the information was posted in the common area. Residents further stated they did not know how to file a grievance and stated they would talk to the nurses if they had a problem. During an interview on 8/21/19 at 11:32 am, Resident #16 stated that with high nursing turnover, he/she was not always sure who the best staff to ask was when issues came up. During an interview on 8/21/19 at 2:03 pm, Resident #6 stated that he/she had not submitted any grievances and further stated he/she felt it would fall on deaf ears. Resident #6 stated he/she thought the grievance process was sending a letter to the ombudsman and/or state agency. During an interview on 8/21/19 at 3:31 pm, the GO stated he/she did not come to the unit to see the Residents. There was no box or forms available on the unit. He/she was asked by the Activities Coordinator (who arranged the Resident Council meetings) to attend and meet the Residents. The GO stated he/she had attended one meeting since January. The GO stated that grievances could be submitted by phone, through contact with the Director of Nurses, or through variance (incident) reports. When asked how a Resident would file an anonymous grievance, the GO stated Residents could have called the organization integrity line. The GO was unsure if the number was posted. Record review on 8/21/19 at 3:40 pm, revealed two grievances documented in the past 12 months. During an interview on 8/23/19 at 11:06 am, the Administrator (AD) and Quality Improvement Coordinator (QIC) stated that they had no concerns about the grievance process. The AD and QIC could not state why the Residents' unresolved complaints had not been forwarded to the facility as grievances, per the facility policy. The AD and QIC stated they had not identified any trends in care for quality improvement based on the two documented grievances received. An observation on 8/23/19 at 12:06 pm, revealed the patient rights posters on the wall in the main hallway. The poster contained the name, email and number of the GO. No additional information was posted on how to file a grievance. Observation on 8/23/19 at 3:31 pm, revealed an 8.5 x 11 sheet of paper with 12 font Arial, bold print taped approximately 5 feet height on the wall behind the dining table seats that stated the Residents had the right to file grievances orally, in writing, and anonymously with a list of numbers and emails. The email for Health Facilities Licensing and Certification was incorrect and the Ombudsman contact number was not to the complaint line, but the direct number for the Ombudsman. There was no specific information on which contact option allowed for an anonymous grievance. Review of the facility policy entitled, Resident Grievance, with an effective date of 3/9/10 revealed Residents and/or families have the right to file grievances orally (meaning spoken) or in writing; and to file grievances anonymously . The policy explained the contact options to include, .telling any caregiver, contacting the grievance officer, calling and leaving voicemail on the local Grievance telephone line or any toll free numbers titled, 'Hotline to the Heart', writing a letter or email to the GO, the LTC Director of Nursing (DON), or Administrator .also directly to the State Health Care Facility Licensing agency or the LTC Ombudsman's Office . The policy stated, When a resident expresses dissatisfaction, or concern or makes a complaint during the episode of care, the caregiver present at the time of complaint: 3:1 Acknowledges the Complaint without expressing judgement and asks the resident what action(s) he/she feels are needed to resolve their concern; 3:2 Resolves the issues independently, at the point of care, as quickly as possible; 3:3 Follows up with the resident after the corrective action to determine if the issue has been resolved to the resident's satisfaction. 3:4 The Caregiver is to file an Electronic Incident Report (EIR) .4. If a resident care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or required further action for resolution, then the complaint is a grievance for the purposes of these requirements. 5. If the issue is not resolved to the resident's satisfaction during the episode of care, the Complaint will be escalated to the Grievance Officer (GO) for resolution, at which time it will be handled as a Grievance. 6. The Director of Nursing, and/or Patient Care Administration will be contacted, who will then contact the Grievance Officer. 7. The caregiver may also contact the GO directly. | 2020-09-01 |