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F0585
D

Failure to Initiate Grievance Process for Missing Resident Property

Frederick, Maryland Survey Completed on 06-30-2025

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

The facility failed to implement its grievance policy when a resident reported missing personal property. Upon admission, the resident brought a wheelchair with leg rests, which were later reported missing for approximately one month. The resident informed the physical therapist, who attempted to locate the missing leg rests and provided alternative leg rests in the meantime. Interviews with staff revealed that although the concern was known to both the physical therapist and a unit nurse, there was no written documentation or formal initiation of the grievance process regarding the missing property. Further interviews confirmed that the standard procedure for missing property was to initiate the grievance process by the first staff member made aware of the issue. The Director of Rehabilitation acknowledged that this process was not followed in the case of the missing wheelchair leg rests. As a result, the facility did not make prompt efforts to resolve the resident's grievance in accordance with its established policy.

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