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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 166 | D | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure: 1) prompt efforts to resolve 2 residents (#s 3 and 4) concerns over lost clothing that was laundered at the facility, 2) prompt efforts to resolve a resident's (#9) concerns related to activities and lost items, and 3) residents (based on a census of 25) knew how to file a grievance with the grievance officer. Failure to ensure complaints and grievances were resolved and residents had access to accurate information on how to file a grievance, placed residents at risk for not having their concerns addressed in a timely manner. Findings: Missing clothing Resident #3 Record review from 5/16-19/17 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. During a group interview on 5/17/17 from 9:00 am - 9:50 am, Resident #3 stated he/she had a white dress shirt that went missing. The Resident stated the facility knew the shirt was missing and had looked for it. The item had not been found or replaced. Resident #4 Record review from 5/16-19/17 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. During a group interview on 5/17/17 from 9:00 am - 9:50 am, Resident #4 stated he/she lost a pair of black pants. The Resident stated the pants went missing around 6 months ago and said at this point they will never show up. The Resident further stated the facility did not offer to replace the pants and told the Resident to make sure the clothing is labeled. During an interview on 5/19/17 at 10:00 am the Activities Staff (AS) #2 stated the facility tried their best to find missing clothing, but we are not responsible (for missing clothing). Additionally, on 5/19/17 at 9:30 am, the facility provided a form titled Lost Item Report. The Charge Nurse (CN) stated activities staff kept track of the missing items using the lost item report form. The CN further stated the facility was only responsible to replace lost medical equipment. During an interview on 5/19/17 at 10:00 am, when asked where the residents lost item report forms were, AS #2 stated he/she did not use this form. Review on 5/19/17 at 9:30 am of the facilities policy, Clothing Labeling and Washing last reviewed 7/14/16, revealed .All clothing and/or personal bedding of a residents is labeled upon admission to the Transitional Care Unit .The resident and/or family member is informed that any new clothing and/or personal bedding brought into the facility must be labeled before being placed in resident's room .If a resident's family member elects to wash the resident's clothing and/or personal bedding the Transitional Care Unit is not respon Follow up on complaint/grievance Resident #9 Record review on 5/17-19/17 revealed Resident #9 was admitted to the facility with a history of depression. Further review revealed Resident #9 was previously transferred from the facility on 3/30/17 and then readmitted on [DATE]. Review of the social worker notes (SW) dated 4/17/17, revealed .Concerns- When pt (patient) was discharged it was reported that pt had a lot of knives in (his/her) room, (he/she) does a lot of art work so currently (he/she) is able to use (his/her) knives in the activity room but (he/she) would like to have them in (his/her) room. (He/She) is still working with LTC management to clear these guidelines up. Review of the care conference notes dated 5/2/17 revealed ACTIVITIES .states that (he/she) wants to do (his/her) hobbies in (his/her) room instead of activities room .enjoys creating things out of anything (he/she) can find and boarders on hoarding. Staff discussed .what could be kept, how long things could be kept, and how the room must be clean. (He/she) is very satisfied when (he/she) creates (his/her) projects. Review on 5/18/17 of Resident #10's comprehensive care plan last revised 5/3/17 revealed Problem: Additional Psych/Social Problem .Goal .Resident will be able to maintain sense of well-being by working on crafts in room . During an interview on 5/17/17 at 10:05 am, Resident #9 stated when he/she was transferred to another facility for a few weeks some of his/her belongings were missing. The missing items were a box of craft supplies and a power cord for a digital camera. Additionally, Resident #9 stated the facility no longer allowed him/her to do his/her arts and crafts projects in his/her room. Resident #9 stated he/she sometimes awakes at night and wants to work on his/her crafts. Resident #9 stated he/she was told he could not have scissors or knives in his room and therefore needs to do his activities in the activity room. The Resident was unaware there was a grievance officer he/she could contact. During an interview on 5/17/17 at 3:45 pm Activity Staff (AS) #1 stated Resident #9 had a history of [REDACTED]. Multiple items had to be boxed up when the Resident had been previously transferred and discharged to the hospital. During an interview on 5/19/17 at 8:50 am the Grievance Officer (GO) stated she had not received any grievances related to Resident #9. During an interview on 5/19/17 at 9:00 am, the Charge Nurse (CN) stated the facility was still working on the issue with Resident #9 being able to do his/her arts and crafts in his/her room. The CN stated there was concern over the health and safety of the Resident's use of carving knives. The CN confirmed the issue was not resolved and stated the issue was brought up at the last care conference meeting. Grievance Officer Information During a group interview on 5/17/17 at 9:00 am - 9:40 am, when asked about filing a complaint or grievance Resident #3 stated he/she was not sure how to file a complaint. Resident #4 stated he/she tells anyone who is handy if he/she has a concern. During an interview on 5/18/17 at 3:00 pm, Resident #9 stated he/she did not know who to contact within the facility to resolve his/her concerns. The Resident stated he/she was not aware of the GO. During an interview on 5/19/17 at 10:00 am Activities Staff (AS) #2 stated if a Resident issue cannot be resolved, it goes to the Director of Nursing (DON). The AS further stated he/she had never notified the GO. During an interview on 5/18/17 at 8:00 am, the GO stated the process for filing a grievance was to call the grievance telephone number, Hotline to the Heart. The GO further stated the grievance telephone line was managed by a staff member (Staff #1). The GO stated Staff #1 either entered the information in the grievance log or informed the GO of the concern. Observation on 5/18/17 at 8:40 am revealed the facility's policy Resident Grievance page 5 was posted in the dining room and at the nurse's station. Review of the POS [REDACTED]. The posting first listed the DON, then facility Administrator, and next the GO. Review on 5/18-19/17 of the facility's policy Resident Grievance last revised 3/9/10 revealed Resident Complaint .Calling and leaving a voice mail on the local Grievance telephone lines or any of the toll-free numbers titled, Hotline to the Heart .Writing a letter or sending an email, expressing dissatisfaction to the LTC (long term care) .DON, Risk Management, or Administration . Additionally, the Resident Grievances policy revealed .Grievances are expressions of dissatisfaction or complaints that cannot be resolved to the resident's satisfaction .All Grievances and investigative review responses are documented . Review on 5/18-19/17 of the facility's Resident Rights and Responsibilities last revised 3/31/17 revealed the last page listed contact information .IF YOU HAVE A COMPLAINT you may file a complaint .concerning resident abuse, neglect, and/or misappropriation of resident property in the facility with . The telephone listed for the GO was different then for the Hotline to the Heart number listed in the Resident Grievance policy. Additional review of the facility's Resident Rights and Responsibilities revealed, Grievance Procedure You have the right to: Voice or write your concerns and complaints to the charge nurse about treatment of [REDACTED]. The Grievance Procedure did not identify that the Residents could contact the grievance officer. | 2020-09-01 |