Nursing Home Resident Complaint — Maine

NURSING HOME / LONG-TERM CARE FACILITY RESIDENT COMPLAINT — STATE OF MAINE

Submit to (check all applicable):

☐ Maine Long-Term Care Ombudsman Program — 1-800-499-0229 — https://www.maineombudsman.org
☐ Maine DHHS Division of Licensing and Certification — 1-800-383-2441 / [email protected]
☐ Adult Protective Services (if abuse/neglect/exploitation) — 1-800-624-8404
☐ Local law enforcement / 9-1-1 (if imminent danger)
☐ U.S. Centers for Medicare & Medicaid Services (CMS) — through DLC as state survey agency

TABLE OF CONTENTS

1. Complainant Information
2. Resident Information and Consent
3. Facility Information
4. Statement of Complaint
5. Federal and State Rights Implicated
6. Imminent-Jeopardy Indicators
7. Internal Grievance History
8. Witnesses and Evidence
9. Relief Requested
10. Authorization, Confidentiality, and Anti-Retaliation
11. Complainant Certification
12. Sources and References

1. COMPLAINANT INFORMATION

2. RESIDENT INFORMATION AND CONSENT

Consent for Ombudsman investigation. The Maine Long-Term Care Ombudsman Program will not investigate without consent of the resident or, if the resident lacks capacity, the resident's legal representative. Check one:

☐ Resident consents to investigation. Resident signature: [________________________________] Date: [__/__/____]
☐ Legal representative consents on resident's behalf (attach proof of authority). Representative signature: [________________________________] Date: [__/__/____]
☐ Consent not yet obtained — Ombudsman is requested to obtain consent through facility visit.

3. FACILITY INFORMATION

4. STATEMENT OF COMPLAINT

4.1 Categories of concern (select all that apply)

Care and treatment:
☐ Pressure injury / wound development or worsening
☐ Falls and fall-related injury
☐ Unaddressed pain
☐ Medication errors / omissions / wrong dose / wrong drug
☐ Failure to follow physician orders or care plan
☐ Inadequate hydration or nutrition / unintended weight loss
☐ Lack of toileting / incontinence care leading to skin breakdown
☐ Failure to obtain timely medical evaluation or hospital transfer
☐ Inadequate infection control (including outbreak response)
☐ Improper use of physical or chemical restraints (incl. antipsychotics)
☐ Failure to provide therapy ordered (PT/OT/ST)
☐ Failure to provide bathing, oral care, grooming
☐ Inadequate dementia or behavioral-health care

Resident dignity and rights:
☐ Verbal abuse, humiliation, or threats by staff
☐ Physical abuse by staff or another resident
☐ Sexual abuse or harassment
☐ Neglect / abandonment
☐ Theft of personal property or money
☐ Misuse of resident funds / personal-needs account
☐ Denied access to telephone, mail, or visitors
☐ Denied access to ombudsman, advocate, attorney, clergy
☐ Retaliation against resident for complaining
☐ Loss of privacy / dignity in care delivery
☐ Failure to honor cultural, religious, dietary preferences

Discharge, transfer, and admission:
☐ Improper involuntary discharge or transfer
☐ Failure to give 30-day notice of discharge/transfer
☐ Discriminatory admission practices (e.g., MaineCare conversion)
☐ Refusal to readmit after hospitalization (bed-hold violation)
☐ Improper "dumping" to hospital ER

Staffing and operations:
☐ Insufficient nursing staff to meet care needs
☐ Untrained or unqualified staff providing care
☐ Failure to maintain adequate records
☐ Failure to schedule or honor care-plan meetings
☐ Failure to investigate or respond to grievances

Financial:
☐ Improper billing (Medicare, MaineCare, private)
☐ Failure to refund deposits or trust funds
☐ Charges for services covered by Medicare/MaineCare
☐ Pressure to sign arbitration or financial responsibility agreements
☐ Other: [________________________________]

4.2 Narrative

Describe the facts giving rise to the complaint. Use objective, observation-based language; identify dates, shifts, staff names where known, and the specific harm or risk to the resident. Quote statements verbatim where possible. Distinguish firsthand observations from statements made by others.

[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

4.3 Specific incidents

5. FEDERAL AND STATE RIGHTS IMPLICATED

The conduct described above implicates one or more of the following residents' rights. (Select all that apply; agency investigators will independently assess applicable rules.)

5.1 Federal Nursing Home Reform Act (Medicare- and Medicaid-certified facilities)

☐ 42 C.F.R. § 483.10(a) — Right to dignified existence, self-determination, communication
☐ 42 C.F.R. § 483.10(c) — Right to participate in care planning and choice of attending physician
☐ 42 C.F.R. § 483.10(e) — Right to privacy and confidentiality
☐ 42 C.F.R. § 483.10(f) — Right to voice grievances without retaliation
☐ 42 C.F.R. § 483.10(g) — Right to information, including medical records and survey results
☐ 42 C.F.R. § 483.10(h) — Right to refuse or discontinue treatment, refuse experimental research, formulate advance directives
☐ 42 C.F.R. § 483.10(j) — Right to be free from interference, coercion, discrimination, retaliation
☐ 42 C.F.R. § 483.12 — Freedom from abuse, neglect, exploitation, and misappropriation of property
☐ 42 C.F.R. § 483.15 — Admission, transfer, and discharge rights (including bed-hold and notice)
☐ 42 C.F.R. § 483.21 — Comprehensive person-centered care planning
☐ 42 C.F.R. § 483.24 — Quality of life
☐ 42 C.F.R. § 483.25 — Quality of care (skin integrity, falls, nutrition, hydration, pain, etc.)
☐ 42 C.F.R. § 483.35 — Sufficient and competent nursing staff
☐ 42 C.F.R. § 483.45 — Pharmacy services / unnecessary drugs / antipsychotic stewardship

5.2 Maine statutes and rules

☐ 22 M.R.S. § 5107-A — Long-Term Care Ombudsman authority (right of access, right to file)
☐ 22 M.R.S. § 7924 — Reporting of violations of resident-rights and resident-care rules to ombudsman
☐ 22 M.R.S. ch. 1665 / formerly cited as 22 M.R.S. § 7901 et seq. — Nursing facility licensure and resident protections
☐ 22 M.R.S. ch. 958-A — Adult Protective Services Act (abuse, neglect, exploitation)
☐ 10-144 C.M.R. ch. 110 — Skilled Nursing and Nursing Facilities licensure (resident rights, care standards, staffing)
☐ 10-144 C.M.R. ch. 113 — Residential Care Facilities (where applicable)
☐ 22 M.R.S. § 1812-G — Resident rights in nursing facilities (verify current section)

6. IMMINENT-JEOPARDY INDICATORS

☐ Resident has sustained serious injury, decline, or death.
☐ Resident is in imminent danger of serious injury (active abuse, severe pressure injury, sepsis risk, elopement risk, suicidal ideation untreated).
☐ Suspected criminal abuse — call ALSO: 1-800-624-8404 (APS) and 9-1-1.
☐ Facility is allegedly attempting to discharge resident on less than 30 days' notice or while appeal pending.
☐ Outbreak / infection-control failure (specify): [________________________________]

If imminent jeopardy exists, this complaint should be conveyed by telephone to DLC at 207-287-9308 / 1-800-383-2441 in addition to written submission.

7. INTERNAL GRIEVANCE HISTORY

Federal and Maine rules require facilities to maintain a grievance process and to respond in writing. 42 C.F.R. § 483.10(j).

Attach copies of any written grievances submitted and written responses received.

8. WITNESSES AND EVIDENCE

8.1 Witnesses

8.2 Documentary and physical evidence

☐ Photographs of injuries, wounds, conditions
☐ Photographs of room / hygiene conditions
☐ Resident's medical record / MAR / progress notes
☐ Care plan and care-conference notes
☐ Incident reports
☐ Facility grievance log entries
☐ Billing statements
☐ Personal-needs account ledger
☐ Discharge / transfer notice
☐ Letters or emails to/from facility
☐ Text messages / voicemails from staff or family
☐ Audio / video recordings (verify Maine recording-consent law before recording)
☐ Hospital records from any transfer
☐ Death certificate (if applicable)

9. RELIEF REQUESTED

The complainant requests that the agency take any and all of the following actions appropriate to the matter:

☐ Open a formal investigation, including unannounced on-site survey
☐ Interview the resident privately and outside the presence of facility staff
☐ Review the resident's complete medical record, MAR, and care plan
☐ Interview the witnesses identified in § 8
☐ Cite deficiencies and require an acceptable Plan of Correction
☐ Impose civil money penalties / denial of payment for new admissions / directed in-service / temporary management as warranted
☐ Refer to law enforcement / Office of the Attorney General / Medicaid Fraud Control Unit (MFCU) where criminal conduct is suspected
☐ Refer to APS for adult protective services if abuse, neglect, or exploitation is found
☐ Stay any pending discharge / transfer pending investigation
☐ Restore wrongly converted resident funds
☐ Provide written investigation findings to the complainant
☐ Take any other action authorized by law

Specific outcome the complainant seeks:

[________________________________]

10. AUTHORIZATION, CONFIDENTIALITY, AND ANTI-RETALIATION

Authorization to release information. I authorize the receiving agency to share the contents of this complaint, with one another and with law enforcement, APS, the Attorney General, MFCU, CMS, and the facility, to the extent necessary to investigate. I authorize health-care providers to release records of the resident relevant to this complaint to the receiving agency. (For Ombudsman matters, ombudsman files remain confidential under 22 M.R.S. § 5107-A absent written consent or court order.)

Request for confidentiality. I request that:

☐ My identity be kept confidential to the extent permitted by law.
☐ The resident's identity be kept confidential to the extent compatible with investigation.
☐ I be notified before my identity is disclosed to the facility.

Anti-retaliation. Federal law (42 C.F.R. § 483.10(j)) and Maine law prohibit retaliation against residents and complainants. If retaliation occurs (denied care, isolation, threatened discharge, withheld property, mistreatment of family visitors, employer discipline of staff complainant), report it immediately to the agencies named on this form.

11. COMPLAINANT CERTIFICATION

I certify under penalty of perjury under the laws of the State of Maine that the statements in this complaint are true and correct to the best of my knowledge and belief, and that I am submitting this complaint in good faith to protect the safety, health, welfare, and rights of the resident named above.

12. SOURCES AND REFERENCES

• Maine Long-Term Care Ombudsman Program: https://www.maineombudsman.org
• Maine DHHS, Division of Licensing and Certification (DLC): https://www.maine.gov/dhhs/dlc
• DLC, File a Complaint: https://www.maine.gov/dhhs/dlc/safety-reporting/file-a-complaint
• Maine DHHS Adult Protective Services: https://www.maine.gov/dhhs/oads/get-support/aps
• 22 M.R.S. § 5107-A (Long-Term Care Ombudsman Program): https://www.mainelegislature.org/legis/statutes/22/title22sec5107-A.html
• 22 M.R.S. § 7924 (Reporting of violations): https://legislature.maine.gov/statutes/22/title22sec7924.html
• 22 M.R.S. ch. 958-A (Adult Protective Services Act): https://www.mainelegislature.org/legis/statutes/22/title22ch958-Asec0.html
• 10-144 C.M.R. ch. 110 (Nursing Facilities licensure rule): https://www.maine.gov/sos/cec/rules/10/chaps10.htm
• 42 U.S.C. § 1395i-3 (Medicare nursing-home requirements): https://www.law.cornell.edu/uscode/text/42/1395i-3
• 42 U.S.C. § 1396r (Medicaid nursing-home requirements / NHRA): https://www.law.cornell.edu/uscode/text/42/1396r
• 42 C.F.R. Part 483, Subpart B (Long-Term Care Facility Requirements): https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B
• CMS Care Compare (facility ratings, surveys): https://www.medicare.gov/care-compare/
• Legal Services for Maine Elders (LSME): https://mainelse.org
• LSME, Resident Rights Handbook: https://mainelse.org/handbook/mainecare-and-long-term-care/resident-rights-what-they-are-and-how-enforce-them
• Maine Resident Rights in Nursing Facilities (Ombudsman Program): https://www.maineombudsman.org/pdf/rights-nursing.pdf

END OF NURSING HOME RESIDENT COMPLAINT