New Hampshire Nursing Home Resident Complaint

NEW HAMPSHIRE NURSING HOME RESIDENT COMPLAINT

TABLE OF CONTENTS

1. Recipient Agencies and Cover Sheet
2. Complainant Information
3. Resident Information
4. Facility Information
5. Statement of Rights Allegedly Violated
6. Detailed Factual Allegations
7. Witnesses, Documents, and Evidence
8. Internal Grievance and Prior Notice to Facility
9. Relief Requested
10. Confidentiality and Anti-Retaliation Notice
11. Complainant Certification
12. New Hampshire Practice Notes
13. Sources and References

1. RECIPIENT AGENCIES AND COVER SHEET

This complaint is being submitted concurrently to the agencies indicated below.

2. COMPLAINANT INFORMATION

3. RESIDENT INFORMATION

4. FACILITY INFORMATION

5. STATEMENT OF RIGHTS ALLEGEDLY VIOLATED

Check each right alleged to have been violated. Citations are to 42 C.F.R. Part 483 (federal NHRA) and RSA 151:21 (NH Patients' Bill of Rights).

A. Federal Nursing Home Reform Act — 42 C.F.R. Part 483

• ☐ § 483.10(a) — Right to be treated with dignity and respect
• ☐ § 483.10(c) — Right to make choices about care, including the right to refuse treatment and to formulate advance directives
• ☐ § 483.10(e) — Privacy and confidentiality
• ☐ § 483.10(g) — Right to be informed of health status, treatment options, and grievance rights
• ☐ § 483.10(j) — Right to file grievances without reprisal
• ☐ § 483.10(g)(14) — Notification of changes in condition
• ☐ § 483.12 — Freedom from abuse, neglect, and exploitation (including misappropriation of property)
• ☐ § 483.12(a)(2) — Freedom from physical or chemical restraints not required to treat medical symptoms
• ☐ § 483.15(a) — Admission rights — facility may not require third-party guarantee or solicit gift as condition of admission
• ☐ § 483.15(c) — Transfer and discharge requirements (notice, bed-hold, appeal)
• ☐ § 483.21 — Comprehensive care plans
• ☐ § 483.24 — Quality of life
• ☐ § 483.25 — Quality of care (including pressure injuries, falls, hydration, medication errors, accidents)
• ☐ § 483.35 — Nursing services / sufficient staffing
• ☐ § 483.45 — Pharmacy / unnecessary drugs / psychotropic medication
• ☐ § 483.70 — Administration
• ☐ § 483.80 — Infection control

B. New Hampshire Patients' Bill of Rights — RSA 151:21

• ☐ § 151:21, I — Treatment with consideration, respect, dignity, and privacy
• ☐ § 151:21, II — Non-discrimination on protected grounds
• ☐ § 151:21, III — Choice of personal physician
• ☐ § 151:21, IV — Information regarding diagnosis, treatment, prognosis
• ☐ § 151:21, V — Informed consent and right to refuse treatment
• ☐ § 151:21, VI — Privacy of treatment and personal needs
• ☐ § 151:21, VII — Confidential treatment of records
• ☐ § 151:21, VIII — Reasonable response to requests
• ☐ § 151:21, IX — Information on continuing health-care needs after discharge
• ☐ § 151:21, X — Information on financial resources for care
• ☐ § 151:21, XI — Refusal to participate in research
• ☐ § 151:21, XII — Continuity of care
• ☐ § 151:21, XIII — Itemized bill / financial information
• ☐ § 151:21, XIV — Visitation by family / personal representative without restriction in terminal illness
• ☐ § 151:21, XV — Right to be free from physical and chemical restraints unless authorized in writing
• ☐ § 151:21, XVI — Right to voice grievances and recommend changes free of reprisal
• ☐ § 151:21, Other (specify): [________________________________]

C. Other

• ☐ Suspected violation of RSA 161-F (abuse / neglect / exploitation of a vulnerable adult)
• ☐ Suspected violation of RSA 631:8 (criminal abuse of elderly / impaired adult)
• ☐ Suspected violation of He-P 803 (NH Nursing Home Rules)
• ☐ Other: [________________________________]

6. DETAILED FACTUAL ALLEGATIONS

6.1. Date(s) and time(s) of alleged conduct. [________________________________]

6.2. Location within the facility. [________________________________]

6.3. Persons involved (staff names, titles, badge numbers; or descriptions if names unknown).

[________________________________]

[________________________________]

6.4. Detailed narrative. Describe what happened, in chronological order. Use specific, observable facts. Include direct quotes when possible. Attach additional pages as needed.

[________________________________]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

6.5. Harm to resident. Describe physical, emotional, psychological, or financial harm:

[________________________________]

[________________________________]

6.6. Pattern allegations. Are there other residents reportedly affected by similar conduct? [___]. If yes, identify (without confidential medical information): [________________________________]

7. WITNESSES, DOCUMENTS, AND EVIDENCE

7.1. Witnesses.

7.2. Available evidence.

• ☐ Photographs of injuries, bedsores, room conditions
• ☐ Resident's medical chart (request through HIPAA authorization)
• ☐ Medication Administration Records (MAR)
• ☐ Care plan and assessment (MDS)
• ☐ Incident reports
• ☐ Nursing notes / progress notes
• ☐ Itemized bills and admission contract
• ☐ Discharge / transfer notice
• ☐ Email / text correspondence with the facility
• ☐ Video / surveillance footage (request preservation immediately)
• ☐ Witness statements
• ☐ Other: [________________________________]

7.3. Litigation hold / preservation request. The complainant requests that the facility preserve all documents, electronic records, video and audio recordings, and physical evidence relating to the resident and the events described herein, pending investigation.

8. INTERNAL GRIEVANCE AND PRIOR NOTICE TO FACILITY

8.1. Has the issue been raised internally with the facility?

• ☐ Yes — describe to whom and when: [________________________________]
• ☐ No — explain why not (e.g., fear of retaliation, immediacy of harm): [___]

8.2. Facility Grievance Official (per 42 C.F.R. § 483.10(j)(4)):

9. RELIEF REQUESTED

The complainant requests that the receiving agency take any and all of the following actions, as appropriate:

• ☐ Immediate on-site investigation by the State Survey Agency / DHHS Health Facilities Administration pursuant to 42 C.F.R. § 488.332.
• ☐ Ombudsman intervention and advocacy under the Older Americans Act § 712 and the NH Long-Term Care Ombudsman program.
• ☐ Adult Protective Services investigation under RSA 161-F:46 and He-E 701.
• ☐ Statement of Deficiencies (CMS-2567) issued, with a Plan of Correction required from the facility.
• ☐ CMS enforcement remedies under 42 C.F.R. § 488.406, including but not limited to:
• ☐ Civil Money Penalties (per-day and per-instance)
• ☐ Denial of Payment for New Admissions (DPNA)
• ☐ Directed Plan of Correction
• ☐ State Monitoring
• ☐ Temporary management / receivership
• ☐ Termination of provider agreement
• ☐ Referral to the NH Office of the Attorney General — Medicaid Fraud Control Unit / Elder Abuse Unit, where indicated.
• ☐ Referral to local law enforcement / county attorney for prosecution under RSA 631:8.
• ☐ Cease and desist any retaliatory conduct against the resident or complainant.
• ☐ Restoration / remediation for the resident, including but not limited to: medical evaluation, staffing changes, care-plan revision, environmental fixes, financial restitution.
• ☐ Written report of the agency's findings and any corrective action ordered.
• ☐ Other relief: [________________________________]

10. CONFIDENTIALITY AND ANTI-RETALIATION NOTICE

10.1. Resident protections from retaliation. Federal regulation 42 C.F.R. § 483.10(j)(1)(iv) and RSA 151:21, XVI guarantee residents the right to voice grievances "without discrimination or reprisal, and without fear of discrimination or reprisal." Any retaliatory transfer, discharge, denial of services, or other adverse action is a separate, independent violation.

10.2. Confidentiality of complainant identity. Reporter / complainant identity is confidential under RSA 161-F:55 and the Long-Term Care Ombudsman confidentiality requirements at 45 C.F.R. § 1324.11(e)(3) and 42 U.S.C. § 3058g(d).

10.3. HIPAA. Where the complainant is the resident's authorized personal representative, this complaint may include protected health information (PHI) consistent with the resident's authorization or applicable HIPAA exception. A signed HIPAA authorization is attached: ☐.

11. COMPLAINANT CERTIFICATION

I declare under penalty of perjury under the laws of the State of New Hampshire and the United States that the foregoing is true and correct to the best of my knowledge, information, and belief, and that I am submitting this complaint in good faith.

[________________________________]

[COMPLAINANT NAME] — Date: [__/__/____]

State of New Hampshire, County of [___]:

Subscribed and sworn before me on [__/__/____].

[________________________________]

Justice of the Peace / Notary Public — Commission expires: [__/__/____]

12. NEW HAMPSHIRE PRACTICE NOTES

• Three-track complaint structure. The Long-Term Care Ombudsman is an advocacy resource that prioritizes resident-directed resolution. The Health Facilities Administration is the regulator and conducts surveys with potential federal enforcement. BEAS APS is the abuse / neglect / exploitation investigator. Submitting in parallel maximizes both advocacy and enforcement.
• Federal NHRA enforcement. When a NH-licensed facility is also Medicare- or Medicaid-certified, federal enforcement remedies under 42 C.F.R. §§ 488.400-488.456 apply. Civil Money Penalties are inflation-adjusted annually. Immediate Jeopardy citations carry the highest per-day CMP range.
• Discharge appeals. A resident facing involuntary discharge or transfer has a right to written notice (generally 30 days, with exceptions) under 42 C.F.R. § 483.15(c) and a right to appeal to the NH DHHS Office of Administrative Appeals. Bed-hold notice is also required.
• Restraints. Both federal (§ 483.12(a)(2)) and state (RSA 151:21, XV) law restrict physical and chemical restraints. "PRN" psychotropic medication orders for behavioral symptoms have additional limits under § 483.45(e).
• Care plans. Residents and their representatives have the right to participate in comprehensive care planning under 42 C.F.R. § 483.21.
• Staffing. § 483.35 requires "sufficient nursing staff." NH does not impose a stricter ratio by statute, but the facility's own staffing plan and the federal sufficiency standard remain enforceable.
• Whistleblower / employee complaints. Employees who witness abuse or neglect have separate mandatory-reporting duties under RSA 161-F:46 and protections against retaliation.
• Civil remedies. Beyond administrative complaints, RSA 151:30 and common-law causes of action (negligence, battery, breach of contract, breach of fiduciary duty, wrongful death) may be pursued in NH Superior Court.
• Time-sensitive evidence. Surveillance video is often overwritten in 14-30 days. A written preservation request to facility administration and legal counsel should be sent immediately.

13. SOURCES AND REFERENCES

• 42 C.F.R. Part 483, Subpart B (Long-Term Care Facilities) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• 42 C.F.R. § 483.10 (Resident rights) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.10
• 42 C.F.R. § 483.12 (Freedom from abuse, neglect, exploitation)
• 42 C.F.R. § 483.15 (Admission, transfer, discharge)
• 42 C.F.R. Part 488, Subpart F (Enforcement remedies)
• RSA 151 — https://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XI-151.htm
• RSA 151:21 (Patients' Bill of Rights) — https://gc.nh.gov/rsa/html/XI/151/151-21.htm
• RSA 151-E (Long-Term Care)
• RSA 161-F (Elderly and Adult Services) — https://www.gencourt.state.nh.us/rsa/html/xii/161-f/161-f-mrg.htm
• N.H. Admin. Code He-P 803 (Nursing Home Rules) — https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/inline-documents/sonh/he-p803-nursing-home-rules.pdf
• DHHS Long-Term Care Ombudsman — https://www.dhhs.nh.gov/about-dhhs/long-term-care-ombudsman
• DHHS Adult Abuse reporting — https://www.dhhs.nh.gov/report-concern/adult-abuse
• CMS Nursing Home Compare / Care Compare — https://www.medicare.gov/care-compare/
• Long-Term Care Ombudsman: 1-800-442-5640 | (603) 271-4375 | [email protected]
• BEAS Adult Protective Services: 1-800-949-0470 | (603) 271-7014
• Emergency: 911

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. If a resident is in immediate danger, call 911. For abuse, neglect, or exploitation suspicion, also file an APS report under RSA 161-F:46. Verify all citations and contact information on dhhs.nh.gov, gencourt.state.nh.us, and ecfr.gov before relying on this form.