Hawaii Nursing Home Resident Complaint — Long-Term Care Ombudsman & Department of Health

HAWAII NURSING HOME / LONG-TERM CARE FACILITY RESIDENT COMPLAINT

TABLE OF CONTENTS

1. Caption / Recipients
2. Complainant and Resident Information
3. Facility Information
4. Statement of Resident Rights Asserted
5. Factual Allegations
6. Specific Violations Alleged
7. Harm Suffered and Damages
8. Relief and Enforcement Sought
9. Authorization, Confidentiality, and Anti-Retaliation
10. Verification
11. Hawaii Practice Notes
12. Sources and References

1. CAPTION / RECIPIENTS

RE: Complaint regarding [FACILITY NAME], license/certification no. [____________________], concerning resident [RESIDENT NAME].

Date of complaint: [__/__/____]

Reference no. (assigned by recipient): [________________________________]

2. COMPLAINANT AND RESIDENT INFORMATION

2.1 Complainant

• Name: [________________________________]
• Relationship to resident: ☐ Resident ☐ Spouse ☐ Adult child ☐ Sibling ☐ Agent under DPOA ☐ Court-appointed guardian/conservator ☐ Healthcare surrogate ☐ Friend/visitor ☐ Staff (current or former) ☐ Other: [________________________________]
• Mailing address: [________________________________]
• Phone: [________________________________]
• Email: [________________________________]
• Authority to act on resident's behalf (attach documentation): ☐ Yes ☐ No

2.2 Resident

• Full legal name: [________________________________]
• Date of birth: [__/__/____]
• Date of admission to facility: [__/__/____]
• Payor source(s): ☐ Medicare ☐ Medicaid (Med-QUEST) ☐ Private pay ☐ Long-term care insurance ☐ VA ☐ Other: [____________________]
• Cognitive status: ☐ Intact ☐ Mild impairment ☐ Moderate impairment ☐ Severe impairment ☐ Unresponsive
• Decision-makers of record:
• Agent under DPOA: [________________________________]
• Healthcare surrogate / agent under AHCD: [________________________________]
• Guardian: [________________________________]
• Primary diagnoses: [________________________________]

3. FACILITY INFORMATION

3.1. Facility name: [________________________________]

3.2. Type: ☐ Skilled nursing facility (SNF) ☐ Intermediate care facility (ICF) ☐ Adult residential care home (ARCH) Type I or Type II ☐ Expanded ARCH ☐ Community care foster family home (CCFFH) ☐ Assisted living facility ☐ Hospital long-term care unit

3.3. Address: [________________________________]

3.4. Hawaii license number / CMS CCN (federal): [____________________]

3.5. Administrator (NHA): [________________________________]

3.6. Director of nursing (DON): [________________________________]

3.7. Owner / parent organization: [________________________________]

3.8. Medicare/Medicaid certification: ☐ Both ☐ Medicare only ☐ Medicaid only ☐ Neither

4. STATEMENT OF RESIDENT RIGHTS ASSERTED

The resident is entitled to the rights guaranteed by the federal Nursing Home Reform Act (42 U.S.C. § 1395i-3 / § 1396r) and 42 C.F.R. § 483.10, and by Hawaii law (HRS Chapter 321; HAR Title 11 Chapter 94 (SNF/ICF) and Chapter 100.1 (ARCH)). Among the rights specifically asserted in this complaint (check each implicated):

• ☐ Right to be free from physical, mental, sexual abuse, corporal punishment, involuntary seclusion (42 C.F.R. § 483.12)
• ☐ Right to be free from neglect, exploitation, and misappropriation of property (42 C.F.R. § 483.12)
• ☐ Right to be free from chemical or physical restraints imposed for discipline or convenience (42 C.F.R. § 483.10(e), § 483.12(a)(2))
• ☐ Right to dignity, privacy, and self-determination (42 C.F.R. § 483.10)
• ☐ Right to participate in care planning and to choose the attending physician (42 C.F.R. § 483.10(c), (d))
• ☐ Right to a comprehensive assessment and an individualized, person-centered care plan (42 C.F.R. § 483.20, § 483.21)
• ☐ Right to quality of care and quality of life sufficient to attain or maintain highest practicable physical, mental, and psychosocial well-being (42 C.F.R. § 483.24, § 483.25)
• ☐ Right to grieve without retaliation (42 C.F.R. § 483.10(j))
• ☐ Right to manage personal funds; protection of resident funds held by facility (42 C.F.R. § 483.10(f)(10))
• ☐ Right to be informed of, and to refuse, treatment (42 C.F.R. § 483.10(c))
• ☐ Right to discharge protections; advance written notice; right to appeal involuntary discharge or transfer (42 C.F.R. § 483.15)
• ☐ Right to access to records, ombudsman, attorneys, and advocacy organizations (42 C.F.R. § 483.10(g)(2), (h), (i))
• ☐ Right to a safe, clean, comfortable, and homelike environment (42 C.F.R. § 483.10(i), § 483.90)
• ☐ Right to nutritious food, hydration, and assistance with eating as needed (42 C.F.R. § 483.60)
• ☐ Right to infection-control protections (42 C.F.R. § 483.80)
• ☐ Hawaii ARCH residents' rights (HRS § 321-15.6; HAR § 11-100.1)
• ☐ Hawaii statutory mandate for the facility to protect health, safety, civil rights, and rights of choice (HRS § 321-15.62 and parallel SNF/ICF rules)

5. FACTUAL ALLEGATIONS

5.1. Date(s) of incident(s) or pattern: From [__/__/____] to [__/__/____].

5.2. Location(s) within the facility: [____________________]

5.3. Staff involved (names, titles, shifts where known): [____________________]

5.4. Detailed narrative (attach additional pages as needed; identify specific care plan goals, MDS findings, MAR entries, or incident reports involved; quote statements where possible; date and time-stamp each event):

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

5.5. Pattern, recurrence, or systemic issues (e.g., chronic short-staffing, repeated falls, repeated medication errors, repeated unanswered call lights):

[____________________________________________________________]

5.6. Prior internal complaints / grievances filed with facility (date, recipient, response):

5.7. Other agencies notified:

• ☐ Adult Protective Services (date: [__/__/____])
• ☐ Police / 911 (date: [__/__/____]; report no.: [____________])
• ☐ CMS / Medicare (date: [__/__/____])
• ☐ Resident's primary physician (date: [__/__/____])
• ☐ DCCA Regulated Industries Complaints Office (RICO) (date: [__/__/____])

5.8. Documentary evidence attached:

• ☐ Photographs (date-stamped)
• ☐ Medical records / chart excerpts
• ☐ Care plan / MDS assessment
• ☐ Medication Administration Record (MAR)
• ☐ Incident reports / facility investigation
• ☐ Billing or trust-fund statements
• ☐ Admission agreement
• ☐ Correspondence with facility
• ☐ Witness statements
• ☐ Audio/video (where lawfully obtained)
• ☐ Other: [____________________]

6. SPECIFIC VIOLATIONS ALLEGED

7. HARM SUFFERED AND DAMAGES

7.1. Physical harm: [____________________]

7.2. Psychological harm: [____________________]

7.3. Financial loss / misappropriation: $[__________] — describe: [____________________]

7.4. Loss of dignity / autonomy / quality of life: [____________________]

7.5. Emergency department visits / hospitalizations attributable to facility conduct: [____________________]

7.6. Mortality risk or wrongful death allegations (if applicable): [____________________]

8. RELIEF AND ENFORCEMENT SOUGHT

The Complainant respectfully requests that the recipient(s):

• ☐ A. Conduct a prompt, on-site, unannounced investigation of the facility.
• ☐ B. Interview the resident outside the presence of facility staff and management.
• ☐ C. Issue a written deficiency citation under the federal F-tag system and the Hawaii license rules where violations are substantiated.
• ☐ D. Impose civil money penalties, denial of payment for new admissions, directed in-service training, directed plan of correction, conditional licensure, license suspension, or license revocation as warranted.
• ☐ E. Refer credible criminal conduct (assault, sexual assault, theft, Medicaid fraud, financial exploitation) to the Hawaii Department of the Attorney General and to county police.
• ☐ F. Coordinate with Adult Protective Services for the resident's safety planning.
• ☐ G. Order the facility to convene an immediate care-planning conference involving the resident, the resident's representative, the attending physician, the DON, and the social worker, and to revise the care plan to address the deficiencies.
• ☐ H. Order restitution of any misappropriated resident funds and an audit of resident trust accounts.
• ☐ I. Reverse, void, or stay any pending involuntary discharge or transfer notice issued in retaliation, and provide the resident the appeal hearing required by 42 C.F.R. § 483.15(c)(3) and Hawaii rules.
• ☐ J. Provide the Complainant a written explanation of investigation findings and corrective action within statutory timeframes.
• ☐ K. Maintain confidentiality of the Complainant's identity to the extent permitted by law and prohibit any retaliation.
• ☐ L. Such further regulatory, advocacy, or legal relief as is appropriate.

9. AUTHORIZATION, CONFIDENTIALITY, AND ANTI-RETALIATION

9.1. Authorization to investigate. The Complainant, on behalf of the resident or as the resident, authorizes the Long-Term Care Ombudsman, the Office of Health Care Assurance, CMS, and Adult Protective Services (as applicable) to access medical, financial, and personnel records reasonably necessary to investigate this complaint, consistent with HIPAA and applicable Hawaii confidentiality law.

9.2. Confidentiality. Pursuant to 45 C.F.R. § 1324.11 (LTC Ombudsman regulations) and 42 C.F.R. § 488.325, the identity of the Complainant and any resident on whose behalf the complaint is made shall not be disclosed without express written consent unless disclosure is required by law.

• ☐ I consent to disclosure of my identity to the facility.
• ☐ I do NOT consent. I request anonymity to the maximum extent permitted by law.

9.3. Anti-retaliation. Federal law (42 C.F.R. § 483.12, § 483.10(j)(4)) and Hawaii licensing rules prohibit any retaliation against the resident, the Complainant, or any witness arising from this complaint. Any retaliatory conduct shall be promptly reported and treated as an additional, independent violation.

10. VERIFICATION

I, [COMPLAINANT NAME], declare under penalty of perjury under the laws of the State of Hawaii that the foregoing is true and correct to the best of my knowledge, information, and belief.

[________________________________]

[COMPLAINANT NAME]

Date: [__/__/____]

Address: [________________________________]

Phone: [________________________________]

(Optional notarization)

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public, State of Hawaii

(My commission expires: [_______________])

11. HAWAII PRACTICE NOTES

• Two distinct enforcement bodies. The Long-Term Care Ombudsman (LTCO), housed in the Executive Office on Aging within the Department of Health, is an independent advocacy office that investigates complaints, advocates for residents, and works to resolve issues at the lowest effective level. It does NOT issue licensing penalties. The Office of Health Care Assurance (OHCA), a regulatory branch of the Department of Health, conducts licensing surveys, investigates substantial complaints, issues deficiency citations, and recommends sanctions.
• Federal vs. state-licensed facilities. Skilled nursing facilities certified for Medicare and/or Medicaid are surveyed under 42 C.F.R. Part 483; OHCA performs the survey on behalf of CMS. Adult residential care homes (Type I and Type II), expanded ARCH, community care foster family homes, and assisted living facilities are licensed and regulated solely under Hawaii law (HRS § 321-15.6, § 321-15.62; HAR Title 11 Ch. 100.1 and Ch. 11) and are not directly subject to 42 C.F.R. Part 483.
• Statewide LTCO contact. 250 South Hotel Street, Suite 406, Honolulu, HI 96813-2831. Toll-free statewide hotline: 1-888-229-2231. Direct: (808) 586-7268. Email: [email protected]. Website: https://www.hi-ltc-ombudsman.org.
• OHCA complaint hotline. (808) 692-7340. Online complaint form available via https://health.hawaii.gov/ohca/.
• CMS complaints. For Medicare- or Medicaid-certified facilities, federal complaints may be filed at https://www.cms.gov or 1-800-MEDICARE.
• Discharge / transfer protections. Federal regulations (42 C.F.R. § 483.15) require 30 days' written notice for most non-emergency involuntary transfers/discharges, with limited exceptions. Residents may appeal to the State (in Hawaii, through the DOH/Med-QUEST hearing process) and the LTCO must be notified.
• Confidentiality and anonymity. LTCO communications and identifying information are confidential under federal law (45 C.F.R. Part 1324) and Hawaii practice. OHCA also protects complainant identity to the extent feasible.
• Concurrent civil remedies. Complaints to the LTCO and OHCA do NOT toll the statute of limitations for civil tort claims. Hawaii's general personal-injury statute of limitations is two years (HRS § 657-7). Wrongful-death actions must be filed within two years (HRS § 663-3, § 657-7). Consult Hawaii counsel.
• Mandatory reporting overlap. Many circumstances giving rise to a facility complaint also trigger mandatory APS reporting under HRS § 346-224. Use the APS report template in parallel.
• Retaliation is its own violation. Document any retaliatory conduct (room change, increased restrictions, transfer notice, billing change, visitation interference) and submit a supplemental complaint. Retaliation may constitute an independent F-tag violation and an unfair practice under Hawaii rule.
• Care-plan focus. Surveyors and ombudsmen routinely audit the comprehensive care plan and MDS 3.0 assessment. Identifying specific care-plan goals or MDS items not implemented (e.g., fall-prevention interventions not provided, pressure-injury repositioning schedules not documented) markedly increases enforcement traction.

12. SOURCES AND REFERENCES

• Hawaii Long-Term Care Ombudsman — https://www.hi-ltc-ombudsman.org (1-888-229-2231)
• Hawaii Executive Office on Aging — https://health.hawaii.gov/eoa/home/long-term-care-ombudsman-program/
• Hawaii Department of Health, Office of Health Care Assurance — https://health.hawaii.gov/ohca/ (Complaint hotline (808) 692-7340)
• HRS Chapter 321 (Department of Health) — https://www.capitol.hawaii.gov/hrscurrent/Vol06_Ch0321-0344/HRS0321/
• HRS § 321-15.6 (Adult Residential Care Homes) — https://www.capitol.hawaii.gov/hrscurrent/Vol06_Ch0321-0344/HRS0321/HRS_0321-0015_0006.htm
• HRS § 321-15.62 (Expanded ARCH) — https://law.justia.com/codes/hawaii/title-19/chapter-321/section-321-15-62/
• HRS Chapter 349 (Executive Office on Aging) — https://www.capitol.hawaii.gov/
• HRS § 349-21 et seq. (Long-Term Care Ombudsman) — https://www.capitol.hawaii.gov/hrscurrent/Vol07_Ch0346-0398/HRS0349/HRS_0349-0021.htm
• 42 U.S.C. § 1395i-3 (Medicare SNF requirements) — https://www.law.cornell.edu/uscode/text/42/1395i-3
• 42 U.S.C. § 1396r (Medicaid NF requirements) — https://www.law.cornell.edu/uscode/text/42/1396r
• 42 C.F.R. Part 483, Subpart B (LTC facility requirements) — https://www.ecfr.gov/current/title-42/part-483/subpart-B
• 45 C.F.R. Part 1324 (LTC Ombudsman program) — https://www.ecfr.gov/current/title-45/part-1324
• CMS Long-Term Care Survey resources — https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo
• Hawaii APS (HRS § 346-224 reports): (808) 832-5115 (Oahu) — https://humanservices.hawaii.gov/ssd/home/adult-services/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Filing this complaint does not toll any civil statute of limitations. In an emergency, call 911 and Adult Protective Services at (808) 832-5115. A Hawaii-licensed elder law attorney should review this complaint before submission, particularly where civil litigation, criminal referral, or wrongful-death claims are anticipated.