Indiana Nursing Home Resident Complaint — Ombudsman / Indiana Department of Health

INDIANA NURSING HOME RESIDENT COMPLAINT — OMBUDSMAN AND ISDH

TABLE OF CONTENTS

1. Routing and Filing Selection
2. Complainant Information
3. Resident Information
4. Facility Information
5. Type of Complaint and Resident Rights Implicated
6. Statement of Facts
7. Witnesses and Evidence
8. Prior Internal Grievance and Facility Response
9. Concurrent Reports
10. Requested Relief
11. Confidentiality and Authorization
12. Complainant Signature
13. Indiana Resident Rights Reference
14. Indiana Practice Notes
15. Sources and References

1. ROUTING AND FILING SELECTION

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

• ☐ Indiana Long-Term Care Ombudsman Program — 1-800-622-4484; [email protected]
• ☐ Indiana Department of Health (ISDH/IDOH), Long-Term Care Complaints Division — 1-800-246-8909
• ☐ CMS (Centers for Medicare & Medicaid Services) — for federally certified facilities, post-state review
• ☐ Indiana Attorney General, Medicaid Fraud Control Unit — for resident-abuse / neglect referrals (Ind. Code § 4-6-10-1.5)
• ☐ Adult Protective Services Hotline 1-800-992-6978 — concurrent referral

Date of complaint: [__/__/____]

Method of submission:

• ☐ Online portal — submission ID: [________________________________]
• ☐ Email — date / address: [________________________________]
• ☐ Telephone — agent / call confirmation #: [________________________________]
• ☐ U.S. Mail / Hand delivery

2. COMPLAINANT INFORMATION

3. RESIDENT INFORMATION

4. FACILITY INFORMATION

5. TYPE OF COMPLAINT AND RESIDENT RIGHTS IMPLICATED

Check all that apply (federal NHRA categories at 42 C.F.R. §§ 483.10, 483.12, and 483.24-25; Indiana parallels at Ind. Code § 16-28-5 and 410 IAC 16.2-3.1):

Abuse / Neglect / Exploitation (42 C.F.R. § 483.12):

• ☐ Physical abuse / battery
• ☐ Verbal / emotional abuse
• ☐ Sexual abuse
• ☐ Mental abuse, including involuntary seclusion
• ☐ Misappropriation of resident property / theft
• ☐ Financial exploitation
• ☐ Neglect — failure to provide goods/services necessary to avoid harm
• ☐ Use of physical or chemical restraints not required to treat medical symptoms

Quality of Care / Quality of Life (42 C.F.R. §§ 483.24, 483.25):

• ☐ Pressure injuries / bedsores not prevented or properly treated
• ☐ Falls / fall-prevention plan inadequate
• ☐ Medication errors / over-medication / unauthorized PRN use
• ☐ Inadequate hydration / nutrition / weight loss
• ☐ Unsanitary conditions / infection control failures
• ☐ Inadequate staffing levels or skill mix
• ☐ Failure to follow comprehensive care plan
• ☐ Failure to provide rehabilitation services
• ☐ Hospice / end-of-life care failures

Resident Rights (42 C.F.R. § 483.10; Ind. Code § 16-28-5):

• ☐ Failure to provide notice of rights at admission
• ☐ Denial of right to participate in care planning
• ☐ Denial of right to refuse treatment / advance directives ignored
• ☐ Denial of access to records
• ☐ Improper transfer / discharge
• ☐ Bed-hold / readmission rights violated
• ☐ Denial of visitation
• ☐ Mail / phone / privacy interference
• ☐ Reprisal or retaliation for filing grievance
• ☐ Denial of right to organize / participate in resident or family council
• ☐ Improper handling of personal funds account

Admission, Transfer, and Discharge (42 C.F.R. § 483.15):

• ☐ Improper involuntary discharge / transfer
• ☐ Inadequate 30-day notice
• ☐ Failure of safe-and-orderly transfer planning
• ☐ "Dumping" to hospital and refusing readmission
• ☐ Improper admission contract / arbitration / third-party guarantor

Other:

• ☐ Substandard quality of life / dignity issues
• ☐ Environmental hazards / safety
• ☐ Specific federal / state regulation: [________________________________]

6. STATEMENT OF FACTS

Provide a clear, chronological, fact-based account. Use "first observed," "told by," and dated entries.

Date(s) of incident or pattern: from [__/__/____] to [__/__/____]

Detailed narrative:

[________________________________]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

Specific staff involved (names, titles, shifts where known):

Observable harm to resident (injuries, weight loss, infections, decline):

7. WITNESSES AND EVIDENCE

Witnesses (residents, family, staff, visitors):

Documentary evidence (attach copies; do not send originals):

• ☐ Medical records / progress notes / MAR
• ☐ Care plan and MDS assessments
• ☐ Incident / fall reports
• ☐ Photographs (date-stamped)
• ☐ Correspondence with facility (emails, letters, grievance forms)
• ☐ Admission agreement and resident-rights acknowledgment
• ☐ Discharge / transfer notice
• ☐ Resident's personal-funds account statement
• ☐ Hospital records following transfer
• ☐ Coroner / death certificate (if applicable)
• ☐ Other: [________________________________]

8. PRIOR INTERNAL GRIEVANCE AND FACILITY RESPONSE

42 C.F.R. § 483.10(j) requires every facility to maintain a grievance process and a designated Grievance Official.

9. CONCURRENT REPORTS

Have any of the following also been notified? Provide reference numbers where available.

10. REQUESTED RELIEF

Complainant requests that the Ombudsman / ISDH (check all that apply):

• ☐ Conduct an immediate on-site, unannounced investigation
• ☐ Interview the resident privately and out of staff hearing
• ☐ Interview identified witnesses confidentially
• ☐ Review medical records, MARs, care plans, MDS assessments, and incident reports
• ☐ Issue findings of deficiencies and require a Plan of Correction
• ☐ Impose civil monetary penalties
• ☐ Recommend denial of payment for new admissions
• ☐ Recommend decertification of the facility
• ☐ Refer for criminal prosecution under Ind. Code §§ 35-46-1-12, 35-46-1-13
• ☐ Refer to Nurse Aide Registry for inclusion of any abusive aide
• ☐ Halt any pending involuntary transfer or discharge
• ☐ Restore misappropriated funds or property to resident
• ☐ Require care-plan revision and credentialed re-training of staff
• ☐ Provide written response to complainant within statutory or regulatory timeframe
• ☐ Other: [________________________________]

11. CONFIDENTIALITY AND AUTHORIZATION

Ombudsman confidentiality (42 U.S.C. § 3058g(d); 45 C.F.R. § 1324.11): The Ombudsman shall not disclose the identity of the complainant or the resident without the express consent of the complainant or resident (or the legal representative where the resident lacks capacity).

I authorize the Long-Term Care Ombudsman, ISDH, and any concurrent investigating agency to:

• ☐ Disclose my identity to the facility for purposes of investigation
• ☐ NOT disclose my identity to the facility — investigate on confidential basis
• ☐ Disclose my identity only with my prior written consent for each disclosure
• ☐ Communicate findings and updates to the resident's authorized representative listed in Section 3
• ☐ Obtain medical, financial, and care-plan records of the resident pursuant to applicable HIPAA and Indiana confidentiality authorizations attached hereto

Complainant initials regarding confidentiality preference: [____]

12. COMPLAINANT SIGNATURE

I, [COMPLAINANT NAME], declare under penalty of perjury under the laws of the State of Indiana that the information set forth in this Complaint is true and complete to the best of my knowledge, information, and belief; that I make this Complaint in good faith; and that I understand both that confidentiality protections apply to my report and that the facility is prohibited from retaliating against me, the resident, or any witness.

Complainant signature: [________________________________]

Print name: [________________________________]

Date: [__/__/____]

If filed by an attorney on behalf of resident:

[________________________________]

[ATTORNEY NAME], Indiana Bar No. [####]

[LAW FIRM]

[ADDRESS / TELEPHONE / EMAIL]

13. INDIANA RESIDENT RIGHTS REFERENCE

Indiana's nursing-facility resident bill of rights at Ind. Code § 16-28-5 and the implementing rules at 410 IAC 16.2-3.1 incorporate and supplement the federal NHRA. Selected rights include:

• Dignity and self-determination. The right to be treated with consideration, respect, and full recognition of dignity and individuality.
• Care planning participation. The right to participate in the development and implementation of the comprehensive care plan, to choose a personal physician, and to be informed in advance about care and treatment.
• Informed consent. The right to be informed of medical condition and treatment in language understandable to the resident, and the right to refuse treatment.
• Freedom from restraints. The right to be free from physical or chemical restraints not required to treat medical symptoms.
• Freedom from abuse. The right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of property.
• Privacy and confidentiality. Privacy in accommodations, medical treatment, written and telephone communications, visits, and meetings of family and resident groups.
• Grievance. The right to voice grievances without discrimination or reprisal and to receive prompt resolution and response.
• Personal funds. The right to manage one's own financial affairs or to receive a quarterly accounting of facility-managed funds.
• Visitation. The right to receive visitors at the resident's discretion (subject only to clinical justification documented in the record).
• Transfer and discharge. The right to remain in the facility absent statutory grounds for transfer or discharge (failure to pay, medical necessity, safety, facility closure, or improvement of resident's condition such that nursing-facility care is no longer needed) and to receive 30 days' written notice with appeal rights.
• Access to Ombudsman. The right to immediate, private access to the Long-Term Care Ombudsman, government regulators, family, and counsel.
• Information about facility status. The right to inspect facility survey results and Plans of Correction.
• Choice of pharmacy. The right to use a pharmacy of the resident's choosing where consistent with facility's medication-management system.
• Resident and family councils. The right to organize and participate in resident or family councils, with required facility cooperation.

Indiana's residential-care / assisted-living rights at 410 IAC 16.2-5 mirror these protections with adjustments for the residential-care setting.

14. INDIANA PRACTICE NOTES

• Two parallel tracks. The Ombudsman is a resident-directed advocate (no enforcement power, but significant influence and federal confidentiality protection). ISDH is the regulator with authority to issue deficiencies, impose civil monetary penalties, deny payment for new admissions, suspend admissions, and recommend decertification. Many complaints benefit from filing with both.
• Federal floor; state ceiling. The federal NHRA at 42 U.S.C. § 1395i-3 / § 1396r and 42 C.F.R. Part 483 sets the floor; Ind. Code § 16-28-5 and 410 IAC 16.2-3.1 supply Indiana-specific overlays. Cite both.
• Investigation timing. ISDH triages complaints by severity. Immediate Jeopardy complaints prompt on-site investigation within two business days; high-priority within ten working days; non-priority within forty-five days. Confirm current ISDH triage policy and CMS State Operations Manual Chapter 5 timelines at filing.
• Discharge / transfer rights. A facility may not transfer or discharge except for limited statutory grounds (42 C.F.R. § 483.15(c); Ind. Code § 16-28-5-1; 410 IAC 16.2-3.1). Discharge requires 30 days' written notice with appeal rights; bed-hold and readmission rights protect Medicaid recipients during hospital and therapeutic leave.
• Arbitration provisions. Federal regulations at 42 C.F.R. § 483.70(n) limit pre-dispute binding arbitration. Document any admission-agreement arbitration clause. Indiana courts apply both the FAA and the Indiana arbitration statutes; case-specific review is required.
• Retaliation. 42 C.F.R. § 483.12(a)(2) and Ind. Code § 16-28-5-3 prohibit retaliation. Document any retaliation contemporaneously and promptly add it as a supplement to this Complaint.
• Concurrent APS report. Where the conduct alleged constitutes abuse, neglect, battery, or exploitation of an endangered adult, also file an APS report at 1-800-992-6978 (see companion APS Report template). The Ombudsman/ISDH track and the APS track operate in parallel.
• Criminal referral. Indiana criminal statutes at Ind. Code §§ 35-46-1-12 (Exploitation) and 35-46-1-13 (Battery / Neglect of an Endangered Adult) apply to facility staff. The Indiana Attorney General Medicaid Fraud Control Unit has jurisdiction over Medicaid-funded facility abuse and neglect cases under Ind. Code § 4-6-10.
• Civil action preserved. A complaint to the Ombudsman or ISDH does not toll Indiana's two-year statute of limitations for personal-injury or wrongful-death claims (Ind. Code § 34-11-2-4). Consult counsel promptly to preserve civil remedies.
• Nurse Aide Registry. Substantiated findings of abuse, neglect, or misappropriation against a Certified Nurse Aide are reported to the Indiana Nurse Aide Registry under 42 C.F.R. § 483.156, barring future employment.
• Public records. Survey results (CMS Form 2567) and Plans of Correction are public and posted on the ISDH and Medicare Care Compare websites — review prior survey history when framing the Complaint.

15. SOURCES AND REFERENCES

• Indiana Long-Term Care Ombudsman — https://www.in.gov/ombudsman/long-term-care-ombudsman/ ; 1-800-622-4484 ; [email protected]
• File a Complaint (Ombudsman) — https://www.in.gov/ombudsman/long-term-care-ombudsman/how-to-file-a-complaint/
• Indiana Department of Health — Long-Term Care Complaints — https://www.in.gov/health/ ; 1-800-246-8909
• Indiana Nursing Home Resident Rights — https://www.in.gov/health/ltc/facility-licensing-and-certification/comprehensive/nursing-home-resident-rights/
• Indiana Code Title 16, Article 28 (Health Facilities) — http://iga.in.gov/legislative/laws/
• 410 IAC 16.2 (Health Facility rules)
• Federal Nursing Home Reform Act — 42 U.S.C. §§ 1395i-3, 1396r
• 42 C.F.R. Part 483 (Long-Term Care Requirements)
• Older Americans Act Long-Term Care Ombudsman Program — 42 U.S.C. § 3058g; 45 C.F.R. § 1324
• CMS Care Compare (facility ratings, surveys) — https://www.medicare.gov/care-compare/
• Indiana Adult Protective Services — 1-800-992-6978; https://www.in.gov/fssa/da/adult-protective-services/
• Indiana Attorney General Medicaid Fraud Control Unit — https://www.in.gov/attorneygeneral/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Indiana long-term-care residents have parallel federal and state rights, and complaints may be filed with multiple agencies simultaneously. Where abuse, neglect, or exploitation is suspected, a separate APS report under Ind. Code § 12-10-3 is required. Counsel licensed in Indiana should review the matter for civil litigation, regulatory, and criminal-referral implications, and to preserve any tort claim within the applicable statute of limitations.