cms_MT: 1541
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1541 | ASPEN MEADOWS HEALTH AND REHABILITATION CENTER | 275140 | 3155 AVE C | BILLINGS | MT | 59102 | 2020-01-02 | 585 | D | 1 | 0 | LFEX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the prompt resolution of a resident grievance, and to maintain evidence demonstrating the result of a resident grievance for 1 (#2) of 6 sampled residents; and the facility failed to notify residents individually, or through postings throughout the facility, of the necessary contact information for the grievance official. This deficient practice resulted in stress and frustration for the resident. Findings include: 1. During an interview on 12/24/19 at 8:50 a.m., resident #2 stated she had been admitted approximately six weeks earlier, after suffering a [MEDICAL CONDITION] at home. Resident #2 stated she was blind, and had been hoping to get into an assisted living facility. Resident #2 stated she had been having a problem with a CNA since first arriving at the facility. Resident #2 stated due to her [MEDICAL CONDITION], she was sensitive to the tone of voice of staff who spoke to her. She stated she had several conversations with the administrator about how a CNA had been gruff and very rude to her. Resident #2 considered these conversations to be complaints, and resident #2 stated she went so far as to request the CNA not care for her. Resident #2 stated the only thing the administrator ever did was to tell the staff member to, Be nicer. Resident #2 stated nothing ever changed. The attitude and treatment by the CNA did not change. Resident #2 stated this had caused her stress and frustration, and she did not know who to trust. During an interview on 12/26/19 at 1:53 p.m., staff member G stated the current Social Service Director was the Grievance Official, but he had been handling some of the complaints due to changes in the Social Services position over the past eight months or so. Staff member G stated he had not been documenting all of the resident concerns in the grievance log. Staff member G stated he asked the resident if they wanted to file a grievance. If the resident said no, staff member G did not document his conversations in the Grievance Log. When asked about the conversations with resident #2, staff member G stated he did not talk to resident #2 more than twice about her problem with the CN[NAME] Staff member G was not able to explain why at least the two conversations with resident #2 were not considered grievances, and therefore, documented in the grievance log. Staff member G could not show documentation demonstrating what corrective action had been taken in an attempt to resolve resident #2's grievances associated with the treatment by the CN[NAME] During an interview on 1/2/20 at 10:31 a.m., staff member J stated the only complaint she was aware of was related to a nurse refusing to give resident #2 a pain pill. When staff member J was told this, she immediately notified staff member [NAME] She believed it might have been a reportable event. Staff member G told her (staff member J), he was already aware of the issue and, was taking care of it. Staff member J relayed the message to resident #2. Staff member J stated resident #2 told her (staff member J) she knew this because she had talked to staff member G about the issue first. Staff member J stated she did not receive any other complaints or grievances from resident #2. Staff member J stated she was not responsible for educating new residents, or their representatives about the grievance process. Staff member J stated she only became aware of her responsibility with regard to grievances several weeks prior to this interview. Staff member J stated that prior to this notification, she believed staff member G was handling all grievances. During an interview on 1/2/20 at 1:35 p.m., staff member S stated she had received several complaints from resident #2 regarding treatment by a particular CN[NAME] Staff member S stated she had taken these concerns to staff member [NAME] Staff member S stated when she received these verbal complaints from resident #2, she interpreted these complaints as grievances, and expected to see a change in the behavior of the CNA towards resident #2. When asked, staff member S stated she had not seen any change in the CNA's treatment of [REDACTED]. Staff member S stated resident #2 liked to have things a certain way, especially because of her [MEDICAL CONDITION], and became easily frustrated with staff. A review of the Grievance Log, dated (MONTH) 2019, showed one grievance by a different resident, related to a dirty room. A review of the Grievance Log, dated (MONTH) 2019, showed four grievances. Three were by the same resident, related to missing clothes, call lights, meds, and a wound. One was related to items being moved. All were resolved, none involved a written decision. None of the grievances listed were by resident #2. Neither of the logs showed any grievances or complaints related to staff treatment of [REDACTED]. A review of the facility's policy, Grievance Procedure, dated (MONTH) (YEAR), showed, .informs the Resident/Resident's Authorized Representative about their right to voice grievances orally, . regarding the care and treatment/lack of treatment, behavior of staff and of other residents, and other concerns during their stay. The policy also showed, Grievances are resolved immediately, when possible, by the individual receiving the grievance. The policy showed, When immediate resolution is not possible, the grievance is routed to the Grievance Official and/or Social Services/designee within 24 hours. The individual receiving the grievance fills out a Grievance Form. Additional documentation related to resident #2's grievance investigations was requested. None was provided prior to the end of the survey. 2. During an observation of the Timbers unit nursing station on 12/26/19 at 1:40 p.m., the grievance posting was seen on the wall at standing eye level. The posting was on white paper with black print. The Grievance Official was listed as (facility name), and the contact information was the general contact information for the facility. There was no name, email, or specific contact information available for residents, or families, to use if they had wanted to file a grievance. There was a box attached to the wall, to the left of the posting, which contained blank grievance forms. Two rolling vital sign carts were placed in front of the posting. These carts were approximately four and a half feet tall, and were partially blocking the view of the posting. It was not possible to reach the blank forms, and it was difficult to see the posting, without moving the vital sign carts. During an observation of the TLC unit nursing station on 12/26/19 at 1:45 p.m., the grievance posting was seen posted on the wall at standing eye level, across from the nursing desk. The posting was located on the wall between room [ROOM NUMBER] and the soiled linen room. The posting was on white paper, with black print. There was no name, email or other contact information for the Grievance Official. During an observation on 12/31/19 at 1:54 p.m., the two rolling vital signs carts were seen placed in front of the grievance posting, blocking access to the grievance forms and obstructing the view of the grievance posting. During an interview on 1/2/20 at 10:31 a.m., staff member J stated she was not responsible for educating residents and their representatives on the grievance process when initially admitted . She stated staff member Q was responsible for this during the admission process. During an interview on 1/2/20 at 12:35 p.m. staff member Q stated all new residents were educated about grievances and signed an Acknowledgement of Receipt. Staff member Q stated this acknowledgement showed the resident received the policy related to the grievance process and was educated. A review of the facility's form titled, Acknowledgement of Receipt Grievance Procedure Policy, updated (MONTH) (YEAR), showed the facility posted the contact information for the Grievance Official, .in prominent areas throughout the Center. The form also showed, .makes Grievance Forms and this policy readily available to residents, family members . The form failed to identify the Grievance Official, or provide any contact information. A review of the facility's policy titled, Grievance Procedure, updated (MONTH) (YEAR), showed, 3. The Center designates a Grievance Official for the Center. Their contact information is posted with the policy in a prominent space. The policy also showed the forms and the policy would be readily available to residents, family, representatives, visitors, and staff members. | 2020-09-01 |