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F0584
D

Failure to Investigate Resident's Report of Missing Clothing

Saint Paul, Minnesota Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with diagnoses including weakness, adult failure to thrive, morbid obesity, and bipolar disorder with psychotic features reported missing clothing items to nursing staff. The resident, who required substantial assistance with dressing and was dependent on staff for lower body dressing, stated she informed a nurse about the missing items but did not recall the nurse's name and did not complete a formal grievance form. The resident reported that the nurse said she would look into the matter, but no further follow-up occurred, and the resident had not received any updates regarding her missing clothing. Interviews with social services, the assistant director of nursing, and the director of nursing revealed that none were aware of the missing clothing until the week of the survey. All agreed that a grievance form should have been completed by the nurse who received the report, in accordance with facility policy, which requires prompt investigation of complaints regarding resident property. The failure to document and investigate the resident's report of missing clothing resulted in the deficiency.

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