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F0585
D

Failure to Implement Grievance Policy for Missing Resident Items

Durham, North Carolina Survey Completed on 05-22-2025

Penalty

Fine: $15,816
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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

The facility failed to implement its grievance policy and procedures when a resident reported missing personal items, specifically self-Cath catheters and an electric wheelchair charger. The resident, who was cognitively intact and had diagnoses including heart failure and paraplegia, reported the missing items to the DON and Administrator immediately after the incident. Despite this, the resident did not receive any resolution or communication regarding the missing items for approximately two weeks. Interviews with staff revealed that the Unit Manager was informed of the missing items and relayed the information to the Social Worker and Administrator but did not complete a grievance form. The Social Worker was aware of the missing catheters but did not file a grievance or follow up, believing that new catheters were being ordered. The Administrator acknowledged being informed of the missing items but did not ensure a grievance was filed or that the issue was resolved within the facility's required five-day timeframe. This resulted in a failure to follow the facility's grievance policy and to promptly address the resident's concerns.

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