North Dakota Nursing Home Resident Complaint (Long-Term Care Ombudsman / DHHS Health Facilities)

NORTH DAKOTA NURSING HOME RESIDENT COMPLAINT

TABLE OF CONTENTS

1. Complainant Information
2. Resident Information and Authorization
3. Facility Information
4. Nature of the Complaint — Resident Rights
5. Statement of Facts
6. Care-Plan and Quality-of-Care Concerns
7. Notice of Transfer/Discharge — Appeal
8. Financial Concerns and Personal Funds
9. Imminent-Jeopardy Determination Requested
10. Witnesses and Evidence
11. Action Requested and Routing
12. Confidentiality, Retaliation, and Resident Consent
13. Signature and Date
14. North Dakota Practice Notes
15. Sources and References

1. COMPLAINANT INFORMATION

2. RESIDENT INFORMATION AND AUTHORIZATION

Resident consent to Ombudsman intervention (preferred where capable):

• ☐ Resident consents in writing — attach consent
• ☐ Resident provides verbal consent (date, witness): [____]
• ☐ Resident lacks capacity; surrogate consents under POA / guardianship — attach authority

3. FACILITY INFORMATION

4. NATURE OF THE COMPLAINT — RESIDENT RIGHTS

Check all violations alleged. Citations are to 42 C.F.R. Part 483 (federal NHRA), N.D.C.C. ch. 50-10.2 (ND Rights of Health Care Facility Residents), and N.D.A.C. ch. 33-07-03.2 (ND nursing-facility licensure rules).

A. Dignity, autonomy, and self-determination — 42 C.F.R. § 483.10:

• ☐ Failure to treat with dignity and respect
• ☐ Denial of choice in activities, schedule, health care
• ☐ Denial of access to personal records or care plan
• ☐ Denial of right to manage own affairs / personal funds
• ☐ Mail, phone, or visitor restrictions
• ☐ Denial of access to ombudsman, advocate, attorney, clergy
• ☐ Failure to provide notice of rights in language and form resident understands

B. Freedom from abuse, neglect, exploitation, and restraint — 42 C.F.R. § 483.12:

• ☐ Physical, verbal, sexual, or mental abuse
• ☐ Involuntary seclusion
• ☐ Misappropriation of resident property
• ☐ Inappropriate physical restraint
• ☐ Inappropriate chemical restraint (psychotropic without indication / consent)
• ☐ Failure to investigate or report alleged abuse

C. Quality of life and quality of care — 42 C.F.R. §§ 483.24, 483.25:

• ☐ Avoidable pressure injuries / wounds
• ☐ Falls without adequate intervention
• ☐ Avoidable weight loss / dehydration / malnutrition
• ☐ Untreated pain / inadequate pain management
• ☐ Untreated incontinence; UTIs; unsanitary conditions
• ☐ Medication errors / omitted doses / wrong route
• ☐ Inadequate dental, vision, hearing, podiatry care
• ☐ Failure to provide rehabilitation services as ordered
• ☐ Failure to attain or maintain highest practicable function

D. Care planning and assessment — 42 C.F.R. §§ 483.20, 483.21:

• ☐ Untimely or absent comprehensive assessment (MDS)
• ☐ Care plan not individualized
• ☐ Resident or representative excluded from care planning

E. Admission, transfer, and discharge — 42 C.F.R. § 483.15:

• ☐ Improper transfer or discharge
• ☐ Inadequate written notice (less than 30 days, missing required content)
• ☐ Failure to permit return after hospitalization (bed-hold)
• ☐ Discrimination based on payor source

F. Staffing and competency — 42 C.F.R. § 483.35; N.D.A.C. ch. 33-07-03.2:

• ☐ Insufficient staffing levels
• ☐ Staff lacking required competency / training
• ☐ No RN coverage as required

G. Environment, infection control, and emergency preparedness — 42 C.F.R. §§ 483.70, 483.80, 483.73:

• ☐ Unsafe building conditions
• ☐ Infection-control failures (outbreak management, isolation, PPE)
• ☐ Emergency-preparedness failures

H. Other [________________________________]

5. STATEMENT OF FACTS

Provide a chronological narrative. Identify dates, times, locations, persons present, and observable facts. Quote statements where possible. Attach photographs, medical records, communications.

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

Narrative:

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

Resident's stated wishes / impact on resident:

[________________________________]

6. CARE-PLAN AND QUALITY-OF-CARE CONCERNS

Internal grievance process exhausted? ☐ Yes — copy of facility response attached ☐ No — explain [____]

7. NOTICE OF TRANSFER/DISCHARGE — APPEAL

Complete only if the facility has issued a transfer or discharge notice.

Resident requests: ☐ Stay of transfer pending appeal ☐ Reversal of discharge ☐ Bed-hold protection ☐ Safe-discharge planning consistent with discharge-summary requirements

8. FINANCIAL CONCERNS AND PERSONAL FUNDS

• ☐ Improper handling of resident personal-funds account
• ☐ Charges for services covered by Medicare/Medicaid
• ☐ Demand for "private pay" or third-party guarantor in violation of 42 C.F.R. § 483.15(a)(3)
• ☐ Failure to advise of Medicaid eligibility / application assistance
• ☐ Failure to provide quarterly statement of personal funds
• ☐ Charges for items required to be furnished by facility
• ☐ Other [____]

9. IMMINENT-JEOPARDY DETERMINATION REQUESTED

Is there a present situation likely to cause serious injury, harm, impairment, or death to a resident? ☐ Yes — REQUEST IMMEDIATE-JEOPARDY SURVEY ☐ No

Basis for request (specific facts): [________________________________]

If yes, the complainant requests parallel notification to:

• ☐ DHHS Health Facilities Section — survey unit (immediate dispatch)
• ☐ Local law enforcement (if criminal conduct suspected)
• ☐ CMS Region 8 (Denver) for federal enforcement
• ☐ Adult Protective Services (companion VAPS report)

10. WITNESSES AND EVIDENCE

Documentary evidence attached:

• ☐ Photographs (with dates)
• ☐ Medical records / MAR / progress notes (signed authorization)
• ☐ Care plan and MDS assessments
• ☐ Notice of transfer/discharge
• ☐ Personal-funds statements
• ☐ Written grievances and facility responses
• ☐ Communications (text, email, letters)
• ☐ Audio/video recordings (consistent with consent rules)
• ☐ Police-incident report numbers
• ☐ Other [____]

11. ACTION REQUESTED AND ROUTING

A. From the Long-Term Care Ombudsman:

• ☐ Confidential, resident-directed advocacy and investigation
• ☐ On-site visit
• ☐ Mediation with facility administration
• ☐ Care-conference attendance
• ☐ Assistance preparing transfer/discharge appeal
• ☐ Coordination with DHHS Health Facilities, VAPS, CMS

B. From DHHS Health Facilities Section (state survey agency):

• ☐ Complaint survey under 42 C.F.R. § 488.332
• ☐ Issuance of Statement of Deficiencies (CMS Form 2567)
• ☐ Civil money penalty / denial of payment / directed plan of correction
• ☐ Referral to CMS for termination, if warranted

C. From CMS Region 8 (Denver):

• ☐ Federal enforcement / oversight of state survey agency
• ☐ Special focus facility designation review

D. From law enforcement / State's Attorney:

• ☐ Criminal investigation of abuse, neglect, theft, exploitation

E. Routing addresses:

12. CONFIDENTIALITY, RETALIATION, AND RESIDENT CONSENT

A. Confidentiality. Under the Older Americans Act (42 U.S.C. § 3058g(d)) and N.D.C.C. ch. 50-10.1, the Long-Term Care Ombudsman cannot disclose the identity of the complainant or resident, or the substance of the complaint, without informed consent. Ombudsman files are not subject to general public-records release.

B. Retaliation prohibited. Federal regulation (42 C.F.R. § 483.10(j)(4)) and ND law prohibit retaliation against a resident for filing a grievance or contacting the Ombudsman. Retaliation is itself a citable deficiency and may support a separate cause of action.

C. Resident-directed advocacy. The Ombudsman acts at the direction of the resident wherever capable. If the resident lacks capacity, the Ombudsman acts in accordance with the resident's expressed wishes to the extent ascertainable, and otherwise in the resident's best interests with input from a legal representative.

13. SIGNATURE AND DATE

I declare under penalty of perjury under the laws of North Dakota that the foregoing complaint is, to the best of my knowledge, true and made in good faith for the protection of the resident named above.

14. NORTH DAKOTA PRACTICE NOTES

1. Single intake line. ND consolidates Ombudsman and APS intake at 1-855-462-5465. Option 2 = VAPS, Option 3 = Ombudsman. Calling either does not preclude the other; for facility cases the agencies coordinate under N.D.C.C. § 50-25.2-04.
2. Ombudsman vs. survey agency. The Ombudsman advocates and mediates; DHHS Health Facilities cites and sanctions. Most serious complaints should go to BOTH so that the resident has both a confidential advocate and a public enforcer.
3. 30-day discharge appeal. Notices of transfer or discharge under 42 C.F.R. § 483.15 must give 30 days' notice (with limited exceptions for emergencies, criminal conduct, non-payment, or facility closure). The appeal window to the state fair-hearing system is short — file immediately on receipt.
4. No private NHRA action. The Eighth Circuit has rejected private damages claims under NHRA itself. Litigation typically proceeds under N.D.C.C. ch. 50-10.2 (state-law resident rights), common-law negligence and breach-of-fiduciary-duty, and breach of admission contract.
5. Arbitration. Federal regulation generally requires arbitration agreements to be voluntary, separate from admission, and revocable. Examine any arbitration clause for compliance with 42 C.F.R. § 483.70(n) before treating it as enforceable.
6. Bed-hold rights. Medicaid bed-hold and return rights under 42 C.F.R. § 483.15(d) are frequently violated after hospitalization; document the date of hospital transfer and any communication about return.
7. Personal-needs allowance. Medicaid residents receive a state-set monthly PNA; misuse of the personal-funds account is a separate citable deficiency under § 483.10(f)(10) and may be theft under N.D.C.C. § 12.1-23.
8. Survey records. Statements of Deficiencies (CMS-2567) for licensed facilities are public; obtain prior surveys to establish history and pattern.
9. Special focus facilities. CMS designates chronically poor performers as "Special Focus Facilities"; designation supports requests for heightened scrutiny and CMS sanctions.
10. Coordinate with discharge planning. Whenever discharge is at issue, ensure the discharge-summary requirements of 42 C.F.R. § 483.21(c)(2) are met and that a safe-discharge location is identified — facilities may not "dump" residents at homeless shelters or unsupported settings.

15. SOURCES AND REFERENCES

• ND HHS — Long-Term Care Ombudsman Program: https://www.hhs.nd.gov/adults-and-aging/human-services/adults-and-aging/long-term-care-ombudsman-program
• ND HHS — Adult and Aging Services: https://www.hhs.nd.gov/adults-and-aging
• ND HHS Aging & Disability Resource-LINK (Carechoice): https://carechoice.nd.assistguide.net/
• N.D.C.C. ch. 50-10.2 (Rights of Health Care Facility Residents): https://law.justia.com/codes/north-dakota/title-50/chapter-50-10.2/
• N.D.C.C. ch. 50-10.1 (Long-Term Care Ombudsman Program): https://ndlegis.gov/cencode/t50c10-1.pdf
• N.D.C.C. § 50-25.2-04 (Referral of Complaints Regarding Long-Term Care Facilities): https://ndlegis.gov/cencode/t50c25-2.pdf
• N.D.A.C. ch. 33-07-03.2 (Nursing Facilities — licensure): https://ndlegis.gov/information/acdata/pdf/33-07-03.2.pdf
• N.D.A.C. ch. 33-03-24.1 (Basic Care Facilities): https://ndlegis.gov/information/acdata/pdf/33-03-24.1.pdf
• 42 C.F.R. Part 483, Subpart B (LTC requirements): https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B
• 42 U.S.C. § 1395i-3 (Medicare NHRA): https://www.law.cornell.edu/uscode/text/42/1395i-3
• 42 U.S.C. § 1396r (Medicaid NHRA): https://www.law.cornell.edu/uscode/text/42/1396r
• Older Americans Act — Long-Term Care Ombudsman Program (42 U.S.C. § 3058g): https://www.law.cornell.edu/uscode/text/42/3058g
• CMS Region 8 (Denver — covers ND): https://www.cms.gov/About-CMS/Agency-Information/RegionalOffices/Denver
• ND Long-Term Care Ombudsman Annual Report (sample): https://ltcombudsman.org/uploads/files/support/nd-LTC-Ombudsman-Annual-Report.pdf
• Consumer Voice — Get Help: https://theconsumervoice.org/get-help/
• Nursinghomecomplaint.org — ND complaint guide: https://nursinghomecomplaint.org/resources/north-dakota-nursing-home-complaint/