Tennessee Nursing Home Resident Rights Complaint (Ombudsman / Department of Health)

TENNESSEE NURSING HOME RESIDENT COMPLAINT

TABLE OF CONTENTS

1. Filing Cover Page
2. Resident Information
3. Complainant Information
4. Facility Information
5. Statement of Rights Violated
6. Factual Narrative
7. Evidence and Witnesses
8. Internal Grievance Steps Taken
9. Requested Relief and Outcome
10. Authorization and Release
11. Complainant Affidavit and Signature
12. Tennessee Practice Notes
13. Sources and References

1. FILING COVER PAGE

[DATE]

Re: Complaint regarding [FACILITY NAME], License No. [________]
Resident: [RESIDENT NAME]
Date of incident(s): [__/__/____] through [__/__/____]

To Whom It May Concern:

I respectfully submit this complaint pursuant to the federal Nursing Home Reform Act (42 U.S.C. § 1395i-3, § 1396r, and 42 C.F.R. Part 483, Subpart B) and the Tennessee nursing home residents' rights statutes (T.C.A. § 68-11-901 et seq.) regarding conditions and treatment at the facility identified above. Detailed information appears in the sections that follow. I request investigation, corrective action, and the relief specified in Section 9.

Respectfully,

[________________________________]

[COMPLAINANT NAME]

[ADDRESS / PHONE / EMAIL]

2. RESIDENT INFORMATION

3. COMPLAINANT INFORMATION

4. FACILITY INFORMATION

5. STATEMENT OF RIGHTS VIOLATED

The conduct complained of violates one or more of the following federal and Tennessee resident rights. Check all that apply.

Federal — 42 C.F.R. § 483.10 et seq. (Nursing Home Reform Act):

☐ § 483.10(a) — Right to be treated with respect and dignity.

☐ § 483.10(b) — Right to exercise rights free from interference, coercion, discrimination, or reprisal.

☐ § 483.10(c) — Right to be informed of and participate in care planning.

☐ § 483.10(e) — Right to privacy and confidentiality of personal and clinical records.

☐ § 483.10(f) — Right to self-determination, choice of physician, and reasonable accommodation.

☐ § 483.10(g) — Right to information about health status and treatment options.

☐ § 483.10(h) — Right to privacy in communications and visitation.

☐ § 483.10(i) — Right to a safe, clean, comfortable, and homelike environment.

☐ § 483.10(j) — Grievance rights and freedom from retaliation.

☐ § 483.12 — Freedom from abuse, neglect, exploitation, and misappropriation of property.

☐ § 483.15 — Admission, transfer, and discharge rights (proper notice and basis).

☐ § 483.20 — Resident assessment (MDS) and care planning.

☐ § 483.21 — Comprehensive person-centered care plan.

☐ § 483.24 — Quality of life (ADLs, activities, mobility).

☐ § 483.25 — Quality of care (pressure ulcers, falls, nutrition, hydration, medication, restraints).

☐ § 483.30 — Physician services.

☐ § 483.35 — Nursing services and adequate staffing.

☐ § 483.40 — Behavioral health services.

☐ § 483.45 — Pharmacy services and unnecessary drugs (chemical restraints).

☐ § 483.55 — Dental services.

☐ § 483.60 — Food and nutrition services.

☐ § 483.70 — Administration.

☐ § 483.80 — Infection control.

☐ § 483.95 — Training requirements.

Tennessee — T.C.A. § 68-11-901 et seq. and Tenn. Comp. R. & Regs. 1200-08-06:

☐ Right to free communication and visitation without restraint, interference, coercion, discrimination, or reprisal.

☐ Right to choose a personal physician with assistance from family or representative.

☐ Right to participate in planning total care and medical treatment.

☐ Freedom from chemical or physical restraints except upon specific written physician order for documented medical necessity.

☐ Freedom from willful abuse or neglect by staff.

☐ Right to confidential treatment of personal and medical records.

☐ Right to dignified existence and privacy.

☐ Right to manage personal financial affairs or have an itemized accounting of any funds entrusted to the facility.

☐ Right to written inventory and protection of personal property.

☐ Right to voice grievances and recommend changes in policies and services without retaliation.

☐ Right to receive proper written notice and grounds before involuntary transfer or discharge.

☐ Right to pre-admission and pre-contract disclosures (T.C.A. § 68-11-910).

6. FACTUAL NARRATIVE

Provide a chronological, factual account distinguishing direct observation from secondary information.

Date(s) and time(s) of incident(s):

[________________________________]

Location within facility (room, hallway, dining, bathroom):

[________________________________]

Staff involved (names, titles, shifts) — if known:

[________________________________]

Description of the incident or pattern of conduct:

[________________________________]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

Resident's physical condition observed (vitals, weight loss, wounds, hygiene, hydration):

[________________________________]

Resident's emotional condition / statements:

[________________________________]

Statements made by staff or facility representatives:

[________________________________]

Pattern, frequency, escalation:

[________________________________]

Specific quality-of-care concerns (check all that apply):

☐ Falls (number / severity / supervision)

☐ Pressure ulcers (location / stage / treatment lapses)

☐ Medication errors / chemical restraint / off-label antipsychotic use

☐ Unexplained injuries / bruising

☐ Weight loss / malnutrition / dehydration

☐ Inadequate hygiene / soiled bedding / odor

☐ Insufficient staffing / call-light response

☐ Failure to provide therapy as ordered

☐ Failure to honor advance directive / DNR

☐ Improper transfer / discharge without statutory notice

☐ Retaliation after grievance

☐ Theft or misappropriation of property / funds

☐ Sexual misconduct or assault

☐ Wandering / elopement

☐ COVID-19 / infection control failure

☐ Other: [____________________________________]

7. EVIDENCE AND WITNESSES

Witnesses:

8. INTERNAL GRIEVANCE STEPS TAKEN

Federal regulation 42 C.F.R. § 483.10(j) requires the facility to maintain a grievance process. Document attempts to resolve internally.

☐ Facility provided written response within required timeframe.

☐ Facility refused or failed to respond.

☐ Retaliation followed grievance — describe: [____________]

9. REQUESTED RELIEF AND OUTCOME

Check all that apply:

☐ Immediate intervention — protect resident from imminent harm.

☐ Investigation by State Survey Agency (Tennessee Department of Health / Health Facilities Commission) under 42 C.F.R. § 488 enforcement scheme.

☐ Plan of correction required of facility.

☐ Civil monetary penalty under T.C.A. § 68-11-803 (Type B) and 42 C.F.R. § 488.408.

☐ Denial of payment for new admissions / termination of provider agreement (CMS).

☐ Mandatory in-service training of staff on issue identified.

☐ Restoration of resident property / funds misappropriated.

☐ Rescission of improper discharge / transfer notice; re-admission.

☐ Substitution of attending physician at resident's election.

☐ Care-plan revision with family / surrogate participation.

☐ Cessation of chemical / physical restraint absent valid clinical justification.

☐ Ombudsman advocacy to mediate ongoing concerns.

☐ Referral to APS (1-888-277-8366) for parallel abuse / neglect investigation.

☐ Referral to law enforcement for criminal conduct.

☐ Preservation of all records pending investigation; spoliation notice attached.

☐ Other: [____________________________________]

Outcome sought (one paragraph):

[________________________________]

[________________________________]

10. AUTHORIZATION AND RELEASE

If the complainant is not the resident, attach proof of authority (POA, conservatorship order, or signed consent below).

RESIDENT CONSENT / RELEASE OF INFORMATION

I, [RESIDENT NAME], authorize the State Long-Term Care Ombudsman, the Tennessee Department of Health / Health Facilities Commission, the Tennessee Department of Human Services Adult Protective Services, and any law enforcement agency receiving this complaint, to:

1. Investigate the matters described herein, including interview of the resident and review of medical, financial, and facility records;
2. Coordinate with one another in the conduct of any investigation; and
3. Disclose the contents of this complaint as necessary to effect the relief requested.

[________________________________]

[RESIDENT NAME] (or surrogate decision-maker, with authority)

Date: [__/__/____]

11. COMPLAINANT AFFIDAVIT AND SIGNATURE

STATE OF TENNESSEE

COUNTY OF [COUNTY]

I, [COMPLAINANT NAME], being first duly sworn, depose and state that I have read the foregoing Complaint, that the contents thereof are true and correct to the best of my knowledge and belief, and that I file the same in good faith pursuant to the Nursing Home Reform Act, T.C.A. § 68-11-901 et seq., and the Tennessee Long-Term Care Ombudsman Program (T.C.A. § 71-2-116 et seq.).

[________________________________]

[COMPLAINANT NAME]

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

[________________________________]

Notary Public, State of Tennessee

(My Commission Expires: [_______________])

12. TENNESSEE PRACTICE NOTES

• Two-track regulatory enforcement. The Long-Term Care Ombudsman is an advocacy program that mediates and elevates resident-driven complaints; the Tennessee Department of Health / Tennessee Health Facilities Commission is the survey-and-enforcement agency that conducts on-site investigations and imposes civil monetary penalties under T.C.A. § 68-11-803 and federal CMS authority.
• Confidentiality of Ombudsman files. The federal Older Americans Act (42 U.S.C. § 3058g(d)) and Tennessee implementing law require that Ombudsman files be kept confidential and disclosed only with the resident's informed consent — a key reason to file with the Ombudsman where confidentiality is desired.
• Survey timelines. Tennessee operates under the federal CMS State Operations Manual. Immediate-jeopardy complaints require investigation within 2 working days; high-priority within 10 working days; routine complaints within longer windows. Confirm with intake.
• Retaliation. Both federal regulation (42 C.F.R. § 483.10(j)) and Tennessee statute prohibit retaliation against a resident or family member for filing a grievance. Retaliation may itself constitute a separate federal deficiency and a Tennessee statutory violation.
• Discharge / transfer rights. Under 42 C.F.R. § 483.15 and T.C.A. § 68-11-901, a facility may not involuntarily discharge or transfer a resident absent enumerated grounds (resident's welfare, improvement, safety of others, non-payment, facility closure) and proper 30-day written notice with appeal rights. Improper discharges should be challenged immediately and reported to the Ombudsman.
• Type B civil monetary penalties. T.C.A. § 68-11-803 authorizes Type B CMPs against the facility for enumerated patients'-rights violations, in addition to any federal CMS sanctions.
• Parallel APS report. Where the complaint involves abuse, neglect, or exploitation, mandatory APS reporting under T.C.A. § 71-6-103 is independent and must be completed (1-888-277-8366) regardless of any facility-level grievance.
• Civil cause of action. Tennessee permits private civil actions for nursing home neglect / negligence and statutory wrongful death claims; consult an elder-law or plaintiff's attorney for limitations periods and potential pre-suit notice or arbitration provisions.
• Records access. Under HIPAA and T.C.A. § 68-11-304, residents and authorized representatives have a right of access to medical records; request in writing and document any delay or denial.
• Federal escalation. Where facility is Medicare/Medicaid certified and Tennessee enforcement is inadequate, complaints may be escalated to CMS Region IV (Atlanta) and to the Office of Inspector General, U.S. Department of Health and Human Services.

13. SOURCES AND REFERENCES

• Tennessee Long-Term Care Ombudsman, Commission on Aging and Disability — https://www.tn.gov/disability-and-aging/disability-aging-programs/long-term-care-ombudsman.html
• District Long-Term Care Ombudsman Directory — https://www.tn.gov/disability-and-aging/disability-aging-programs/long-term-care-ombudsman/district-long-term-care-ombudsman.html
• Tennessee Department of Health, Health Care Facilities — https://www.tn.gov/health
• Tennessee Health Facilities Commission — https://www.tn.gov/hfc
• Tenn. Comp. R. & Regs. 1200-08-06 (Standards for Nursing Homes) — https://publications.tnsosfiles.com/rules/1200/1200-08/1200-08-06.20210818.pdf
• T.C.A. § 68-11-901 et seq. (Rights of Nursing Home Residents) — https://law.justia.com/codes/tennessee/title-68/health/chapter-11/part-9/
• T.C.A. § 68-11-803 (Type B civil monetary penalties) — https://law.justia.com/codes/tennessee/2021/title-68/chapter-11/part-8/section-68-11-803/
• 42 C.F.R. Part 483 Subpart B (Federal LTC Requirements) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• 42 U.S.C. § 1395i-3 / § 1396r (Nursing Home Reform Act) — https://www.govinfo.gov
• 42 U.S.C. § 3058g (State Long-Term Care Ombudsman Program) — https://www.govinfo.gov
• CMS Nursing Home Compare — https://www.medicare.gov/care-compare
• Tennessee APS hotline (parallel reporting): 1-888-277-8366
• Tennessee Department of Health complaint hotline: 1-877-287-0010
• State LTC Ombudsman: 1-877-236-0013 / 615-253-5412

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Tennessee-licensed attorney should be consulted before pursuing administrative or civil action against a nursing facility. Where a resident is in immediate danger, call 911 first and file this complaint afterward.