| 117 |
HERITAGE PLACE |
275025 |
171 HERITAGE WAY |
KALISPELL |
MT |
59901 |
2017-11-22 |
166 |
D |
1 |
0 |
D7BM11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to identify a Grievance Officer; failed to promptly follow-up on a grievance, document the date the original grievance was filed, notify the resident in writing of the decision, and document the date the written decision was issued for 1 (#2) of 11 sampled and supplemental residents. Findings include: 1. Resident #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident was discharged to another facility on 11/3/17. During an interview on 11/21/17 at 9:36 a.m., resident #2's family member stated the day the resident was discharged on [DATE], he did not have his dentures in his mouth. She stated she asked the facility staff where his dentures were and she was told one of the CNAs took his dentures out the night before around 2:00 a.m. She stated she and the facility staff both looked in the room, the dining room, and other areas where the resident's dentures might have been placed. She was told by the facility staff they will file a concern regarding the missing dentures and had planned to follow up with her about the outcome. The family member stated she did not hear back for over a week from the facility. She stated she called several times during that week and left messages to have staff member A and/or staff member C call her back regarding the missing dentures. She stated she called for a third time a week later to follow up with the Staff member A, whether facility had found resident #2's dentures. She stated when she called, she was told by the person whom answered the phone, they believed they had found the dentures and she could come and pick them up. When she arrived at the facility, she was told staff member A wanted to discuss something with her first. She stated when she entered the staff member A's office, he held up a broken partial and told her they thought they had found resident #2's dentures. She explained to staff member A, the item they found was a partial, and not the resident's dentures. She stated staff member A told her the resident put his dentures in his pillowcase and they broke in half, and that was all that was left of the resident's dentures. She stated she had explained to staff member A, the resident had never placed his dentures in his pillowcase and the partial he was trying to claim was his fathers, was not. She told staff member A she had an invoice for the dentures in her vehicle and she would be happy to provide that to him for reimbursement of the lost dentures. She stated staff member A had proceeded to tell her it was not their responsibility but the resident's for putting the dentures in his pillowcase. Resident #2's family member stated she attempted to follow-up a couple more times with staff member A about the missing dentures and was told by staff member A they were still looking for the dentures and to call him back next week because he was currently too busy. She stated she called the staff member again on 11/21/17 and he told her to send in the invoice and they will review the cost, but he told her they could not commit to the cost of the dentures; and explained they were not sure yet if they would replace the cost or not. She stated she was not satisfied the grievance had been resolved as of 11/21/17. She stated since the dentures were lost on 11/3/17, she had made several attempts to contact the facility via the phone and left several messages, never hearing back. She stated she even called the hot-line number, which was posted in the entryway of the facility. She was told by the person on the hotline, either staff member A or C would call her back. She stated she never heard back from either staff member. She stated she had not received a letter of resolution on the grievance. Review of the facility's Grievance Log, showed a grievance was logged on 11/3/17 for resident #2, regarding missing dentures, the outcome was written as, initiating staff interviews relating the lost dentures. The grievance was not marked resolved and did not identify on the log the responsible associate for the investigation and follow-up of the concern. Review of resident #2's Grievance/Concern Report Form, dated 11/10/17, failed to establish the date and time the incident occurred. The nature of the grievance was marked as missing item. The following summary was written, (staff member C) looked in room, nurse station, nourishment room, laundry, and nurse cart for teeth (both dentures) not found. Interview with staff members, all staff state he kept taking them out and leaving them in blankets, wrapped in napkin, pocket for some reason he could not keep them in his mouth. The person responsible for follow up was left blank. The action taken to address grievance showed, waiting for faxed copy of invoice from (resident #2's family member). Administrator spoke with her 11/22/17 at 0900. The date of follow up with resident was written in as, discharged . The section which asked if the grievance was resolved within 72 hours, was checked no, but no additional documentation was provided for rationale. The form was signed completed by staff member A on 11/21/17. The grievance form failed to identify the date the original grievance was filed, which was 11/3/17. The facility failed to respond promptly with a written resolution for resident #2. During an interview on 11/20/17 at 7:00 p.m., staff member A stated staff member C had found resident #2's dentures in a pillowcase the Friday after the resident discharged . Staff member A stated they facility was still investigating the loss of the dentures. Staff member A stated the family member never brought an invoice in to him so they could consider replacing the dentures. During an interview on 11/21/17 at 1:30 p.m., staff member A stated it was the expectation to follow up on a grievance within 72 hours. He stated that time frame was difficult to follow because the facility was very busy. He stated he was the responsible individual for investigating the grievance for resident #2. He stated the resident was restless and kept removing his teeth, and putting his teeth in various places in his room. He stated staff member C searched in several different places and found his dentures in a pillowcase. He stated he called and left a message for resident #2's family member to let her know they had found the dentures. He stated he did not document the discovery of the dentures or the phone call to the family member. Staff member A stated there was no possible way to document everything he did for resident #2. Staff member A stated he did not have a Grievance Officer at the time of the grievance was placed by resident #2, so he managed the grievance. Staff member A stated resident #2's family member was angry and was demanding a check for the dentures. He stated he was still considering the missing dentures and had not completed the investigation yet. He stated even though he had signed the grievance form as completed, the investigation was not yet complete. He stated he did not have time to consider the missing dentures, and it did not do any good to spend hours looking for the missing dentures, since they were lost. Staff member A stated he planned to write a statement for the grievance regarding resident #2, showing what he did and did not do, as well as claiming the grievance was still under investigation. During an interview on 11/27/17 at 10:00 a.m., resident #2's family member stated she heard back from staff member A on Friday (11/24/17), and was told they would send a check to resident #2's dentist for the lost dentures. The facility failed to establish a Grievance Officer, and failed to accurately document time and date, in writing, the resolution of the grievance for resident #2. During an interview on 11/22/17 at 12:10 p.m., staff member B stated it was the expectation of the facility to identify a Grievance Officer, and follow up on any grievance with the outcome and resolution of the investigation. A review of the facility's policy and Procedure titled, Grievance/Concern, showed, To ensure the resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Such grievances include those with respect to care and treatment which have been furnished as well as that which has not been furnished, the behavior of staff and of other resident; and other concerns regarding their LTC facility stay. b. Thorough postings, in prominent locations throughout facility of the right to file grievances orally or in writing, the right to file grievances anonymously, the contact information of a grievance official with whom a grievance can be filed: name/mailing and/or email address; business phone number, that facility's policy is to complete and review results with resident/resident representative within 72 hours of receipt of concern/grievance; their right to receive a written decision regarding concern/grievance; and include contact information of independent entities with whom grievances may be filed .c. Will be responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility of all information associated with grievances; issuing written grievance decisions to the resident . |
2020-09-01 |