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F0585
D

Failure to Provide Adequate Grievance Follow-Up After Alleged Neglect

Baltimore, Maryland Survey Completed on 08-29-2025

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 was admitted to the facility for therapy and antibiotics. On a night shift, the resident repeatedly used the call-light to request assistance with changing out of a soiled brief, but did not receive help. The resident's family submitted a grievance alleging that a GNA failed to provide any activities of daily living during that shift. The grievance form indicated that the employee was terminated, but there was no documentation of follow-up with the resident or family regarding the resolution of the grievance. During an interview, the resident expressed ongoing distress and fear, stating they had not received any follow-up and were unsure if the staff member involved would return. The DON stated that follow-up had occurred, but was unable to provide documentation to support this. Review of the facility's grievance policy showed requirements for keeping residents informed of progress and issuing a written decision at the conclusion of the investigation, but these steps were not documented in this case.

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