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TEXAS HEALTH HUGULEY HOSPITAL FORT WORTH SOUTH

11801 SOUTH FREEWAY

BURLESON, TX 76028

PATIENT RIGHTS: REVIEW OF GRIEVANCES

Tag No.: A0119

Based on record review and interviews, the hospital's governing body failed to be responsible for the effective operation of the grievance process in that an incident alleged by one of one patient (Patient #1) was not investigated at the time of staff notification on 02/05/14 until 02/24/14.

Findings included:

The hospital's Visit Information dated 02/03/14 at 04:10 reflected Patient #1's admission. The document noted the patient was discharged on 02/10/14 at 10:25.

Physician Order Entry dated 02/03/14 at 04:12 reflected Patient #1's admission diagnoses included Suicidal Ideation and Alcohol Dependency.

Patient #1's undated journal entry noted an incident during her inter-hospital transfer.

Hospital Employee #4 stated on 03/05/14 around 12:10 that Patient #1 had shown her the journal entry two days after admission [on 02/05/14]. Hospital Employee #4 stated she notified Hospital Employee #9 and Hospital Employee #3 and "assumed that it was taken care of."

Hospital Employee #9 was telephone interviewed on 03/06/14 at 08:44 and stated she was aware of Patient #1's journal entry and "...all we did was copy it and put it in the [patient] chart."

Hospital Employee #3 was interviewed on 03/06/14 around 09:15 and stated she learned about the incident after Patient #1's discharge. Hospital Employee #3 stated she and Hospital Employee #4 reviewed Patient #1's chart. Hospital Employee #3 stated, "Unfortunately, that's where I left it."

Hospital Employee #2 stated on 03/06/14 at 10:05 that incident investigations were initiated on 02/24/14. An incident report was completed on 02/25/14.

Hospital Policy RI1011 dated 02/2012 noted that "...all verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance for the purpose of this policy. Methods of Reporting and Resolution included that ...if the charge nurse is unable to resolve the [patient] concern/complaint, she/he will report directly to the Department Director/Nursing Supervisor..."