cms_AK: 80
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 80 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-03-15 | 585 | F | 1 | 0 | M2PE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation and interview, the facility failed to ensure a method for grievances to be filed anonymously and/or verbally. This failed practice had the potential to affect all residents in the facility (based on a census of 48) and denied residents and interested parties the ability to exercise their rights by filing grievances anonymously or to have their concerns recieved verbally. Findings: Observation on 3/14/18 at 9:00-9:15 am of the facility dining rooms, revealed a large monitor screen that flashed information about the facility rules and activities. The information included the residents right to file a grievance and the grievances officer information was listed. In addition, the screen included information about the residents and/or their families right to file a grievance verbally and anonymously. There was no information on the screen, or on the bulletin board, located across the room, that instructed people on how to file a grievance anonymously. There were no forms, used for filing complaints in the area, nor was there an obvious secure place to put the forms once they had been filled out. Anonymous/ Verbal Grievances Resident #2 Record review on 3/14-15/18 revealed Resident #2 was admitted to the facility with a [DIAGNOSES REDACTED]. The Resident was receiving MS ([MEDICATION NAME] sulfate) via a PCA (patient controlled [MEDICATION NAME]) for pain management. During an interview on 3/14/18 at 10:50 am, Resident #2's Family Member stated he/she had expressed several concerns to facility staff about the care Resident #2 had been receiving. When asked if he/she had ever filed a grievance or complaint with the facility, the Family Member stated he/she approached the Shift Supervisor about it a couple weeks ago, and was handed a bunch of forms to fill out. The Family Member did not want to have to fill out forms and stated he/she had a stack of these forms. During the interview the Family Member stated he/she came in yesterday afternoon to find Resident #2 had pulled out his/her indwelling urinary catheter and the Resident's bedding was saturated with urine. The Family Member stated the Director of Nursing (DON) promised him/her that would never happen to Resident #2 again. During an interview with Licensed Nurse (LN) #1 on 3/14/18 at 10:00 am, when asked how a resident and/ or family member could file an anonymous grievance, the LN stated he/she would get them the form and the complainant could just leave their name off the form. When the surveyor pointed out the LN would know who the complainant was, LN #1 responded I wouldn't say anything. During an interview on 3/14/18 at 2:00 pm, when asked how Residents and their families were to file a grievance, Shift Supervisor (SS) #1 stated she would have them fill out a concern form. When asked if residents and their families could file a grievance verbally, the SS stated it was best to have it written down, for tracking reasons. When asked how a resident or family member could file a grievance anonymously, the SS stated the phone number and email information was posted on the wall in the dinning room. The SS was unable to provide information on how to file a written grievance anonymously. Further interview and record review revealed the Family Member continued to have concerns regarding Resident #2's care and pain management at the facility. During a second interview on 3/15/18 at 9:45 am, Resident #2's Family Member stated when his/her daughter had come in to visit the Resident on 3/14/18 at about 3:00 pm, the Resident had soiled him/herself and the room had an odor so putrid the window had to be cracked open. The Family Member went on to state the PCA had run out of MS, Resident #2's family had pressed the call light; the bell had sounded for 17 minutes before someone responded. Review of the Social Service Notes, dated 2/9/18, revealed Writer placed call to .Life Partner (Family Member) .stated currently in (Resident #2's) room and there was a smell of urine (his/her) room. Writer did speak with the DON and she and the writer went to the room and (Family Member) had opened the window to clear the smell. Writer noticed a smell this time .shirt was wet determined it was from the mattress and thus the mattress was changed out and the floor was cleaned. Review of the medical record revealed a late entry nursing note for 3/9/18 charted 3/14/18 at 11:18 am, Looked in (Resident #2's) room noticed the PCA pump was flashing stating the MS was empty. Asked who turned off the alarm, daughter stated she had. Asked he if she had pressed call light, she stated yes. Went and spoke with CNA's they stated no one had answered call light and that none of them knew the PCA alarm was going off. Went back changed MS. Asked family who came in and answered call light. They stated they had turned off the call light themselves .informed them not to touch the PCA pump . During an interview on 3/15/18 at 1:20 pm, when asked about the incident with Resident #2 yesterday, LN #1 stated the event with the PCA pump had happened last week. The LN stated yesterday he/she knew it was about to run out and was waiting to change the MS syringe, so the unused MS wouldn't be wasted. The LN stated the Resident was incontinent of stool yesterday afternoon. Resident #3 During an interview on 3/14/18 at 12:25 pm, Resident #3's Family Member was asked about the facilities grievance process, specifically if implementations were in place to ensure anonymous filing, the Family Member stated No. The Family Member stated he/she was afraid to file a grievance because he/she didn't want the staff to retaliate or be upset with Resident #3. The Family Member stated he/she had been instructed to fill out a form and return it to the nursing manager, the Family Member stated he/she didn't want to fill the form out. During an interview on 3/15/18 at 1:30 pm with the Administrator and DON, when asked how a resident or family member could submit a grievance anonymously and maintain confidentiality, the Administrator stated the concern/grievance could be filled out without names or the grievance could be emailed or left on the phone # as voice message. When asked where anonymous complainants would place the completed form, the Administrator and DON stated the complainant could just place it under the door of the shift supervisor or the social worker. Random observations during the survey on 3/14-15/18 revealed the shift supervisor and social worker doors were often open during the day. Record review on 3/14-15/18 of the facilities As a Resident, you have the Right, revision date 12/17 stated residents have the right to file grievances anonymously. There were no instructions how to file anonymously. Record review on 3/14-15/18 of the form provided to residents/families to file grievances titled, Concern/Feedback Communication form #559.006f, revision date 7/17, revealed no mechanism to file anonymously. Record review on 3/14-15/18 of facility policy titled Resident Concerns and Grievances revision date 12/14/17 revealed in section C subsection 2, Concerns and grievances may be submitted anonymously. The policy revealed no mechanism for filing anonymously. | 2020-09-01 |