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F0585
D

Failure to Identify Grievance Official and Resolve Resident Grievance

Hagerstown, Maryland Survey Completed on 05-14-2025

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 properly identify a Grievance Official in its grievance policy, ensure the policy was followed for processing grievances, and make prompt efforts to resolve a resident's grievance. A resident reported missing hearing aids to staff, who acknowledged the complaint but did not initiate or follow the formal grievance process. The grievance policy reviewed by surveyors was incomplete, lacking the name and contact information of the Grievance Official. Staff interviews revealed confusion about the grievance process, with some staff unaware of their responsibilities or the steps required to resolve grievances. Grievance forms were not readily available at the nurses' station as expected, and there was no clear documentation or follow-up on the resident's complaint. A review of the grievance log showed that the resident had previously filed a grievance regarding the missing hearing aids, which was marked as resolved and signed by the Nursing Home Administrator. However, the resident continued to report the hearing aids as missing, and staff members, including the Social Services Department and unit manager, were unaware of the grievance or its resolution. The Nursing Home Administrator, who identified himself as the Grievance Official, was also unaware of the grievance filed months earlier and acknowledged that the process had failed the resident.

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