F0585

D

Failure to Follow Grievance Process and Communicate Outcomes to Resident Representative

Towson, Maryland Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its grievance process and to honor a resident’s and resident representative’s right to voice grievances without discrimination or reprisal. A resident representative submitted multiple Complaint/Grievance Forms in January and February 2025 regarding the resident’s care, treatment, staff behavior, and quality of life. These grievances included concerns about staff not responding to requests for water during a period when the resident was on large amounts of antibiotics and had limited upper body mobility, staff failing to turn and reposition the resident during the night shift despite requests, and repeated unfulfilled requests to place the resident in a chair so the resident could participate in activities.

Additional grievances documented by the representative included allegations of inadequate pain management, lack of follow-up or care planning for a right foot infection despite prescribed antibiotics and ongoing pain, and absence of a podiatry consult or appointment. The representative also reported being denied access to daily nursing staff information until they produced POA documentation, complaints of increasing spasms and ear pain that were reported to the physician without resolution by a later date, and being told that a specific chair to get the resident out of bed was unavailable even though the representative observed the chair in the hallway outside the room. Further grievances described concerns about rodents in the resident’s room, multiple infections acquired within one month (bedsores, UTI, right foot infection, possible finger infection, and apparent infections in both ears), and a request for a meeting with the complete care team due to concerns that a comprehensive care plan meeting all of the resident’s needs had not been developed and implemented.

Record review showed that the facility’s Complaint/Grievance Forms state that a facility representative will review and contact the complainant within 72 hours, and that the bottom portion of the form is to be completed by the facility representative, including findings, how the issue was resolved, referral information, date received, and date shared with the complainant. For this resident, the facility completed only the findings and resolution sections and the forms were signed by a Grievance Officer (signature unknown to staff) and by NHA #1, all dated 2/6/2025, even though NHA #1’s hire date was 2/24/2025. The sections for “Referred to,” “Date Form Received,” and “Date shared with the person filing the complaint/grievance” were left blank. The resident representative reported that the facility never acknowledged receipt of the grievances, did not inform them of the progress of any investigation, and did not share findings or resolutions. The DON confirmed the grievance process as written, but could not explain the documentation discrepancies or the lack of acknowledgment and communication, and documentation of a written decision to the resident representative, as required by the facility’s Resident and Family Grievances policy, was not provided.