HospitalInspections.org

Based on document review and interview the facility/governing body failed to implement and follow the established grievance process. The patient representative #1 submitted a written grievance and was not afforded the established process by the facilities established grievance process.

A review of the document titled "Grievance and Complaint Process" revealed
A. 1. A patient grievance "is defined as" a written as verbal complaint (when the verbal complaint is not resolved at the time of the complaint by staff present) by a patient as the patient's representative regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS(Centers for Medicare Services) Hospital COPS (Conditions of Participation), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489.
The purpose of this policy is to:
A. 1. Provide a standardized form to document complaints and, or grievances received by the hospital.
2. Provide a process to review, investigate, and resolve a patient's/patient representative's complaint / grievance within a reasonable time frame (time frames specified on the Patient & Family Complaint and Grievance Form).
Policy:
A. 1. Providing quality care with a personal touch is the ultimate goal of the staff of the facility. Patients have the right to express concerns and expect resolution in a timely manner....
a. CEO: writing and sending response letters to patient/family ....
D. The Hospital Quality improvement Committee ensures the patient is provided written notice of its decision regarding a complaint/grievance within 7 days of the Hospitals receipt of the grievance, even though the hospital's resolution need not be complete within the seven-day limit. The written notice shall contain the following:
1. Name of the Hospital contact person.
2. Steps taken on behalf of the patient to investigate the grievance.
3. Results of the grievance process.
4. Date of completion."

A review of the document titled "Event Detail Summary" revealed staff #2 spoke with patient representative #1 on 6/02/2014 about concerns patient #2's discharge on 6/1/2014. She reports concern over his discharge "to an unsafe environment when he is a danger to self and others."
A review of the facility's written response to the patient representative dated June 5, 2014 revealed:
"Providing quality care with a personal touch is the ultimate goal of the staff at Hospital #1. We thank you for bringing your concerns to our attention. The following is a response to your recent information regarding an opportunity for us to improve our services and provide the quality of care our customers expect and deserve.
We understand your concern to be your husband's most recent stay at our facility.
I feel it is important for you to be aware that your concern has been forwarded to my Office and the matter has been reviewed. We apologize that we did not meet your expectations.
Should you have any further questions regarding this matter please feel free to contact me at XXX-XXX-XXXX or any member of our Hospital Administration team Again, thank you for bringing this matter to our attention."
The response was signed by the facility Chief Executive Officer.
The facility's written response failed to include:
1. Steps taken on behalf of the patient to investigate the grievance.
2. Results of the grievance process.
3. Date of completion.
An interview was held on 8/12/2014 at approximately 12:00PM in the Administrative Conference Room with staff #2, and #4. Staff #2, and staff #4 confirmed the facility's written response failed to include:
1. Steps taken on behalf of the patient to investigate the grievance.
2. Results of the grievance process.
3. Date of completion.

Intakes: TX00199072

Based on document review and interview the facility failed to ensure the physician ordered Case Management consult was implemented and followed. A Case Management Consult was order by the admitting physician for discharge planning for Alcohol Abuse Rehab on patient.

A review of the Admission orders dated 05/31/2014 and timed at 15:00 (3:00 PM) revealed "Consults: Case Management for discharge planning for Alcohol Abuse Rehab on pt."

A review of the documents provided by the facility detailing/documenting Case Managements involvement with patient #2's hospital admission from 05/30/2014 to 06/01/2014 revealed no evidence Case Management implemented the physician's order dated 05/31/2014 and timed at 15:00 (3:00 PM) for "Case Management for discharge planning for Alcohol Abuse Rehab on pt."

An interview 8/12/2014 at approximately 10:00AM in the Administrative Conference Room was held with staff #2 and staff #3. Staff #2 and staff #3 after reviewing the Case Managements documents confirmed the physician's order dated 05/31/2014 and timed at 15:00 (3:00 PM) for "Case Management for discharge planning for Alcohol Abuse Rehab on pt." had not been followed or implemented by Case Management.

Based on document review and interview the facility failed to ensure the physician ordered Case Management consult was implemented and followed. A Case Management Consult was ordered by the admitting physician for discharge planning for Alcohol Abuse Rehab on patient.

A review of the Admission orders dated 05/31/2014 and timed at 15:00 (3:00 PM) revealed "Consults: Case Management for discharge planning for Alcohol Abuse Rehab on pt."

A review of the documents provided by the facility detailing/documenting Case Management's involvement with patient #2's hospital admission from 05/30/2014 to 06/01/2014 revealed no evidence Case Management implemented the physician's order for discharge planning.

An interview 8/12/2014 at approximately 10:00AM in the Administrative Conference Room was held with staff #2 and #3. After reviewing the Case Management documents, Staff #2 and #3 confirmed the physician's order had not been followed or implemented by Case Management.