Delaware Nursing Home Resident Complaint (LTC Ombudsman / DHSS)

DELAWARE NURSING HOME RESIDENT COMPLAINT

TABLE OF CONTENTS

1. Recipient Agencies
2. Complainant Information
3. Resident Information
4. Facility Information
5. Statement of Complaint
6. Rights Violated (16 Del. C. § 1121 and 42 C.F.R. § 483.10)
7. Specific Incidents
8. Evidence Inventory
9. Prior Internal Grievance and Facility Response
10. Relief Requested
11. Resident Consent and Authorization
12. Verification
13. Service / Distribution List
14. Delaware Practice Notes
15. Sources and References

1. RECIPIENT AGENCIES

This complaint is directed to (check all that apply):

• ☐ Long-Term Care Ombudsman (resident-directed advocacy)
• ☐ Division of Health Care Quality (regulatory investigation)
• ☐ Adult Protective Services (abuse / neglect / exploitation)
• ☐ Attorney General — MFCU (criminal / Medicaid fraud)
• ☐ CMS Region 3 (federal certification concern)

2. COMPLAINANT INFORMATION

3. RESIDENT INFORMATION

4. FACILITY INFORMATION

5. STATEMENT OF COMPLAINT

Provide a chronological narrative. State facts personally observed and identify sources for any second-hand information. Avoid legal conclusions.

[________________________________________________________________]

[________________________________________________________________]

[________________________________________________________________]

[________________________________________________________________]

[________________________________________________________________]

[________________________________________________________________]

[________________________________________________________________]

[________________________________________________________________]

Date(s) of conduct complained of: [__/__/____] through [__/__/____]

Persons involved: [________________________________]

Witnesses: [________________________________]

6. RIGHTS VIOLATED (16 Del. C. § 1121 AND 42 C.F.R. § 483.10)

The conduct described above violates the following enumerated rights. Mark all that apply.

Federal NHRA / 42 C.F.R. Part 483

• ☐ § 483.10(a) — Right to a dignified existence and self-determination
• ☐ § 483.10(c) — Right to be informed and participate in care planning
• ☐ § 483.10(d) — Right to choose physician and treatment
• ☐ § 483.10(e) — Right to privacy and confidentiality
• ☐ § 483.10(f) — Right to voice grievances without reprisal
• ☐ § 483.10(g) — Right to information (records, surveys)
• ☐ § 483.10(j) — Right to refuse transfer to another room
• ☐ § 483.12(a) — Freedom from abuse, neglect, and exploitation
• ☐ § 483.12(b) — Right to be free from physical or chemical restraints imposed for purposes of discipline or convenience
• ☐ § 483.15 — Admission, transfer, and discharge protections (including 30-day written notice)
• ☐ § 483.24 — Quality of life (ADLs maintained or improved)
• ☐ § 483.25 — Quality of care (pressure ulcers, falls, medication, hydration)
• ☐ § 483.45 — Pharmacy services (unnecessary drugs, antipsychotics)
• ☐ § 483.70 — Administration (sufficient staffing and resources)
• ☐ § 483.95 — Training requirements

Delaware bill of rights — 16 Del. C. § 1121

• ☐ Right to be treated with consideration, respect, and full recognition of dignity and individuality
• ☐ Right to participate in planning of medical treatment and refuse medication / treatment
• ☐ Right to inspect personal records within 24 hours of oral or written request
• ☐ Right to confidential treatment of records
• ☐ Right to privacy in treatment and personal needs
• ☐ Right to be free from mental and physical abuse and from chemical and physical restraints (except as authorized in writing by a physician for a limited period)
• ☐ Right to manage personal financial affairs
• ☐ Right to be discharged only for medical, welfare, or non-payment reasons with 30-day written notice
• ☐ Right to associate and communicate privately with persons of resident's choice (visitation, phone, mail)
• ☐ Right to retain and use personal possessions
• ☐ Right to present grievances to facility, DHSS, P&A agency, or other persons WITHOUT FEAR OF REPRISAL, restraint, interference, coercion, or discrimination
• ☐ Right to participate in social, religious, and community activities
• ☐ Right to a safe, clean, and homelike environment
• ☐ Other right under § 1121 (specify): [________________________________]

Delaware administrative regulations — 16 Del. Admin. C. § 3201

• ☐ Staffing ratios / minimum direct-care hours
• ☐ Infection control and reporting
• ☐ Care plan deficiencies
• ☐ Medication administration / MAR errors
• ☐ Other (specify): [________________________________]

7. SPECIFIC INCIDENTS

For each incident, attach: (a) a detailed factual narrative; (b) supporting evidence; (c) the resident's response and any injuries; and (d) the facility's response, if any.

8. EVIDENCE INVENTORY

• ☐ Photographs / videos (specify): [________________________________]
• ☐ Medical records / progress notes
• ☐ Medication administration records (MAR)
• ☐ Care plan and assessment (MDS) excerpts
• ☐ Physician orders
• ☐ Facility incident reports (request copies under 16 Del. C. § 1121)
• ☐ Visitor / family logs
• ☐ Correspondence with administrator / DON
• ☐ Bank or trust statements (financial exploitation cases)
• ☐ Text messages, emails, voicemails
• ☐ Witness statements / declarations
• ☐ DHCQ / CMS Form 2567 Statements of Deficiencies (prior surveys)
• ☐ CMS Five-Star Quality Rating history
• ☐ State Operations Manual (Appendix PP) cross-references
• ☐ Other: [________________________________]

9. PRIOR INTERNAL GRIEVANCE AND FACILITY RESPONSE

Before submitting this external complaint, the following internal steps were taken (mark all that apply):

• ☐ Verbal complaint to charge nurse on [__/__/____]
• ☐ Verbal complaint to DON on [__/__/____]
• ☐ Written complaint to administrator on [__/__/____]
• ☐ Care plan meeting raised concern on [__/__/____]
• ☐ Resident council / family council notification
• ☐ Written grievance under facility's grievance policy on [__/__/____]
• ☐ Resident requested medical record copies on [__/__/____]
• ☐ No internal step possible due to [ ☐ retaliation risk ☐ urgent harm ☐ resident isolated ☐ other ]

Facility's response (date / decision-maker / outcome):

[________________________________________________________________]

10. RELIEF REQUESTED

The complainant respectfully requests that the receiving agency:

• ☐ Conduct an on-site, unannounced investigation of the facility
• ☐ Issue a Statement of Deficiencies (Form CMS-2567) and require a Plan of Correction
• ☐ Impose civil money penalties or denial of payment for new admissions where warranted
• ☐ Refer to law enforcement / Attorney General's MFCU
• ☐ Order facility to cease and desist the discharge / transfer pending resident's appeal
• ☐ Order facility to permit visitation, communication, or access to records
• ☐ Order facility to revise the resident's care plan to address identified harm
• ☐ Order facility to staff at minimum levels and document compliance
• ☐ Refer the resident to APS for protective services
• ☐ Notify CMS of pattern of substandard quality of care under 42 C.F.R. § 488.404
• ☐ Provide complainant with written notice of disposition under 16 Del. C. § 1125
• ☐ Other relief: [________________________________]

11. RESIDENT CONSENT AND AUTHORIZATION

The Long-Term Care Ombudsman cannot disclose resident-identifying information or take action on a resident's behalf without consent. 45 C.F.R. § 1324.11(e)(3).

If the resident personally signs:

I, [RESIDENT NAME], consent to the filing of this complaint and authorize the Long-Term Care Ombudsman, the Division of Health Care Quality, and Adult Protective Services to investigate, communicate with my care providers, and disclose information necessary for that investigation.

Date: [__/__/____]

Resident signature: [________________________________]

If signed by representative:

I, [REPRESENTATIVE NAME], am the resident's [ ☐ DPOA ☐ healthcare proxy ☐ guardian ☐ next of kin ] and consent on the resident's behalf based on [basis for authority].

Date: [__/__/____]

Representative signature: [________________________________]

12. VERIFICATION

I declare under penalty of perjury under the laws of the State of Delaware that the foregoing complaint is true and correct to the best of my knowledge and belief and is filed in good faith. I understand that retaliation against a resident or complainant for filing a good-faith complaint is prohibited under 16 Del. C. § 1121 and 42 C.F.R. § 483.10(j).

Date: [__/__/____]

Signature: [________________________________]

Print name: [________________________________]

13. SERVICE / DISTRIBUTION LIST

Copies of this complaint were transmitted on [__/__/____] to:

• ☐ Delaware Long-Term Care Ombudsman — 1-855-773-1002 / [email protected]
• ☐ Division of Health Care Quality — 1-877-453-0012 / https://dhss.delaware.gov/dhcq/mailform/
• ☐ Adult Protective Services — 1-888-APS-4302 / https://dhss.delaware.gov/dsaapd/aps/
• ☐ Attorney General — Medicaid Fraud Control Unit — 1-800-220-5424
• ☐ Facility administrator (if not confidential): [________________________________]
• ☐ Resident's primary care physician: [________________________________]
• ☐ CMS Region 3 (Philadelphia)
• ☐ Disability Rights Delaware (P&A agency) — 1-800-292-7980
• ☐ Other: [________________________________]

[________________________________]

[COMPLAINANT NAME]

14. DELAWARE PRACTICE NOTES

• Ombudsman vs. DHCQ — different roles. The LTC Ombudsman is a resident-directed advocate whose authority is bounded by resident consent (or best-interest determination for incapacitated residents without representatives). DHCQ is the regulator with subpoena, survey, and licensure authority. For most quality-of-care complaints, file BOTH so that resident-directed advocacy proceeds in parallel with regulatory investigation.
• Federal NHRA (OBRA '87). Delaware nursing facilities certified for Medicare/Medicaid must comply with 42 C.F.R. Part 483, Subpart B. The CMS State Operations Manual, Appendix PP, is the authoritative interpretive guidance. Citations to specific F-tags (e.g., F600 abuse, F689 falls, F684 quality of care) sharpen complaints.
• Delaware's bill of rights (§ 1121) is broader than federal. It includes 42 enumerated rights and applies across long-term care settings — including assisted living and rest residential facilities not federally certified — extending protections beyond Medicare/Medicaid SNFs.
• 30-day discharge notice. Under 42 C.F.R. § 483.15(c) and 16 Del. C. § 1127, a facility may discharge or transfer a resident only for the six enumerated reasons (e.g., welfare, non-payment, ceased operations) and must give 30 days' written notice with appeal rights. "Hospital dumping" — admitting to a hospital and refusing to readmit — is a frequent violation.
• Retaliation prohibited. 42 C.F.R. § 483.10(j) and 16 Del. C. § 1121 expressly prohibit reprisal for filing grievances. Document any retaliatory adverse action (room change, schedule change, visitor restriction, discharge initiation) and supplement the complaint.
• Federal facility self-reporting. Under 42 C.F.R. § 483.12(c), facilities must report reasonable suspicion of crime causing serious bodily injury to law enforcement and CMS within 2 hours, and other reasonable suspicion within 24 hours. A facility's failure to self-report is independently citable (F609).
• Civil enforcement. 16 Del. C. § 1132 authorizes civil penalties against facilities. Private rights of action under § 1121 have been recognized in Delaware courts; a complainant should consult counsel about parallel civil litigation, including negligence, wrongful death, and consumer-fraud claims.
• Anonymity vs. follow-up. A complainant may file anonymously, but anonymous complaints limit the investigator's ability to follow up. Identifying to the agency only — with confidentiality from the facility — is usually optimal.
• Records access. 16 Del. C. § 1121 requires the facility to permit a resident to inspect records within 24 hours of an oral or written request. Federal HIPAA rights to records (45 C.F.R. § 164.524) provide a parallel federal cause of action.

15. SOURCES AND REFERENCES

• 42 U.S.C. § 1395i-3 / § 1396r (Nursing Home Reform Act)
• 42 C.F.R. Part 483, Subpart B — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• 42 C.F.R. § 483.10 (Resident rights), § 483.12 (Abuse/neglect), § 483.15 (Admission/transfer/discharge)
• CMS State Operations Manual, Appendix PP — https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1201984
• Older Americans Act / LTC Ombudsman — 42 U.S.C. § 3058g
• 45 C.F.R. Part 1324 (Ombudsman regulations)
• 16 Del. C. Chapter 11 — https://delcode.delaware.gov/title16/c011/index.html
• 16 Del. C. § 1121 (Resident's rights) — https://delcode.delaware.gov/title16/c011/sc02/index.html
• 16 Del. Admin. C. § 3201 (Skilled and Intermediate Care Nursing Facilities) — https://regulations.delaware.gov/AdminCode/title16/Department%20of%20Health%20and%20Social%20Services/Division%20of%20Long%20Term%20Care%20Residents%20Protection/3201.shtml
• Delaware Long-Term Care Ombudsman Program — https://dhss.delaware.gov/ltcop/
• Delaware Division of Health Care Quality — https://dhss.delaware.gov/dhcq/
• DHCQ Complaint Form — https://dhss.delaware.gov/dhcq/mailform/
• Adult Protective Services — https://dhss.delaware.gov/dsaapd/aps/
• Disability Rights Delaware (P&A agency) — https://disabilityrightsde.org/
• CMS Care Compare (Five-Star Quality Rating) — https://www.medicare.gov/care-compare/

Disclaimer: This template is provided for informational purposes only and is not legal advice. Facility retaliation is a serious risk; before filing, residents and families should review options with a Delaware-licensed elder law or long-term care attorney, particularly where the resident faces imminent transfer, discharge, or significant injury. The agencies listed above respond on independent timelines and may have overlapping or competing jurisdiction; coordinated filing is recommended.