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Based on record review and interview, the facility failed to ensure the effective operation of their grievance process in accordance with their policy by failing to review and resolve a grievance alleged for 1 of 1 Patient's reviewed (Patient #1). Patient #1's representative/mother alleged allegations of abuse/assault by facility staff; and complaints regarding the quality of care Patient #1 received while at the facility.

As of 05/04/16, Patient #1's representative/mother had not received resolution of her grievance, or a written response from the facility with adequate information to include: steps taken on behalf of Patient #1 to investigate the grievance, the results of the grievance process, and the date of completion in accordance with the facility's Grievance policy.

This deficient practice affected Patient #1's rights when the facility failed to resolve Patient #1's representative/mother's concerns, complaints, and grievance related to Patient #1's rights, safety, and satisfaction.

Findings included:

Complaint # TX 00234959

Review of the facility's Patient Grievance Policy/Complaint Resolution, last revised 11/2014 revealed the following, in part:

Definition of, "Grievance: a formal or informal written or verbal complaint that is made to [the facility] or [facility] employees by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to [facility's] compliance with the CMS [Centers for Medicaid & Medicare Services] Hospital Conditions of Participation (COP's), or a Medicare beneficiary billing complaint." Definition of Verbal Complaint included, a verbal complaint was a patient grievance if: "A. the complaint involves abuse, neglect, patient harm, or hospital compliance with COP's. E. Requires investigation and/or requires further actions for resolution."

Further review revealed any facility employee who receives a grievance from a patient, family, visitor or other customer will proceed as follows: "i. B. Grievances alleging patient, family member or visitor harm or those threatening legal action should be immediately forwarded to Quality Compliance Department and/or the Risk Management Department. V. Within an average of seven (7) working days from the date of the grievance receipt from the patient, family member or visitor, the Patient Grievance Committee shall, in conjunction with the General Counsel, send a written acknowledgment of the grievance to the patient, family member or visitor, which shall include the follow-up actions taken and/or the outcome of any investigation or corrective action. Such documentation will include:
A. The decision of the hospital;
B. The name of a contact person at the hospital;
C. The steps the hospital has taken to investigate the grievance;
D. The result of the grievance process; and
E. The date of completion."


Record review of the Department of State Health Services (DSHS) Complaint/Incident Investigation Narrative Report dated 03/15/16 revealed Patient #1's representative/mother alleged that her son/Patient #1 had been abused/assaulted by staff at this facility after she observed bruises and injuries to his face. Patient #1's representative/mother indicated she called and notified the facility's Behavioral Health (BH) Director of the specific allegations of abuse, neglect, and concerns with his quality of care.


Record review of Patient #1's facility electronic health records (EHR) revealed he was a 21 year-old male, presented to the facility's BH unit on 12/25/15 and was discharged on 12/30/15 to the local Police Department following an alleged physical assault on a facility staff member who was assigned his 1 to 1 supervision and caused injury. Further review of Patient #1's EHR revealed documented incidents of self-injurious behaviors of hitting self in the face, hitting head on wall, choking self, throwing self on the floor, jumping off his bed and trying to head dive. Patient #1's nose was documented swollen and very red along with facial injuries documented.

Record review of the facility's internal investigation review dated 12/30/15 for Patient #1 and titled; Assault Event (Including Removal of Patient by Police Department) revealed the following:

"There are multiple reports, verbal and written, from nursing and medical staff describing how patient engaged in violent episodes where he would attack patients and staff alike and without provocation. Patient is documented as having sustained injuries resulting from self-injurious behavior and which required medical evaluation the days prior to incident in question. Self-injurious behavior included patient hitting his own face, banging his head, running into doors and walls, and even head diving onto the floor." Patient #1's representative/mother met with the Director of BH and other facility staff on 12/31/15. During this meeting it was documented in the facility's investigation the Patient #1's representative/mother was concerned that Patient #1 was not receiving the treatment he needed.

The facility documented on 01/17/16 at 19:29; received a call from Admissions Clerk that Patient #1's representative/mother had been by the facility and started to yell telling patients not to bring their family here.

The facility documented on 01/08/16 at 10:00 AM, met with Patient #1's representative/mother and the this meeting "was the total opposite of what took place on 12/31/15" as Patient #1's representative/mother was "very angry and viewed everything said as negative. They spoke of lawyers and going to the media outlets to report the incident and even mentioned that her daughter was in Austin assumedly looking to file a complaint as they blame us for what happened to patient while in police custody and threaten to hold us accountable if something else happens to patient."

The facility's internal investigation included "Recommendations for Improvement Strategies" specifically regarding this incident event on 12/30/15. The facility's internal investigation did not include evidence that this incident resulting in allegations from Patient #1's representative/mother that her son was abused, neglected, and did not receive adequate care was addressed and resolved in accordance with the facility's Patient Grievance Policy/Complaint Resolution. In addition, there was no evidence that the facility's Patient Grievance Committee reviewed and ensured follow-up actions taken and/or the outcome of the investigation was completed with written acknowledgment sent to the patient's family member.

During an interview on 05/03/16 at 04:18 PM with the BH Director stated he met with Patient #1's representative/mother in 01/2016 and she was "very upset and blaming staff for his [Patient #1] facial injuries" during his hospitalization 12/25/15 to 12/30/15.

During an interview on 05/04/16 at 11:15 AM with Patient #1's representative/mother indicated she was concerned about her son's care received at the facility when she observed him on 12/31/15 and his face, eyes, and lips were swollen with injuries. She indicated that Patient #1 told her [representative/mother] that he was in a "fight" at the facility with a staff member and the staff "hit him." Patient #1's representative/mother indicated she reported this specific allegation to the BH Director the first part of January 2016. She indicated she reported that she wanted this complaint/grievance documented and further stated she wanted to know what happened. Patient #1's representative/mother stated she reported to the BH Director that she felt her son was "neglected;" because there was not enough staff, they did not do their job, and there was lack of care. Patient #1's representative/mother indicated she has not heard back from the facility regarding the outcome of her specific allegations or that the facility has completed an investigation regarding these specific allegations.

During an interview on 05/04/16 at 11:20 AM with the facility's General Counsel A confirmed the facility failed to follow the facility's Patient Grievance Policy/Complaint Resolution which included allegations from Patient #1's representative/mother regarding abuse, neglect, and Patient #1's care. General Counsel A further confirmed there was not a review by the Patient Grievance Committee or a written acknowledgment of the grievance to the patient's family member. General Counsel A indicated there should have been a grievance review; and further stated, "it didn't click to do the grievance process" because the facility was addressing the incident as a "Process Variance Analysis" (PVA) due to Patient #1 being discharge to the local PD. General Counsel stated the facility's internal PVA process should have been a "separate" and independent review because it was not really related to the specific complaints made by Patient #1's representative/mother.

Based on record review and interview the facility failed to ensure the Discharge summary was accurately written and reflected the actual disposition of care for 1 of 1 Patient reviewed (Patient #1).

Specifically, Patient #1's Discharge Disposition documented he was stable and discharged home into the care of a family member; but actually was discharged to the local Police Department for alleged physical assault.

Findings included:

Record review of Patient #1's Registered Nurse (RN) A nursing note on 12/30/15 at 19:30 revealed Patient (Pt.) #1 "attacked and injured the psych tech [A] doing 1:1 monitoring." The Behavioral Health (BH) Director was notified and recommended to notify Medical Doctor (M.D.) A and see if patient can be discharged to the local Police Department (PD). Outgoing RN-B received orders from M.D. A to "discharge Pt. to PD." Further RN A nursing note on 12/30/15 at 19:59 revealed "PD was called and notified."

Record review of the facility's internal investigation review dated 12/30/15 for Patient #1 and titled; Assault Event (Including Removal of Patient by Police Department) revealed the local PD took Patient #1 after charges were filed against him for assault of psych tech A.

Record review of Patient #1's Discharge Summary dated 01/05/16 and electronically signed by M.D. A, who gave verbal orders to RN-B to "discharge Pt. to PD," revealed the Discharge Summary indicated Patient #1's Discharge Disposition was "stable, discharge to home into the care of family member." This Discharge Disposition was not accurate as Patient #1 was alleged to have assaulted a facility staff member and was discharged to the local PD with charges filed against him for physical assault.

During the exit conference on 12/04/16 at 12:30 PM the Chief Nursing Officer (CNO) confirmed that Patient #1's Discharge Summary dated 01/05/16 and electronically signed by M.D. A was not accurate as to the final discharge disposition of Patient #1. The CNO indicated she would follow-up with M.D. A regarding Patient #1's Discharge Summary.

Based on record review and interview, the facility failed to ensure the effective operation of their grievance process in accordance with their policy by failing to review and resolve a grievance alleged for 1 of 1 Patient's reviewed (Patient #1). Patient #1's representative/mother alleged allegations of abuse/assault by facility staff; and complaints regarding the quality of care Patient #1 received while at the facility.

As of 05/04/16, Patient #1's representative/mother had not received resolution of her grievance, or a written response from the facility with adequate information to include: steps taken on behalf of Patient #1 to investigate the grievance, the results of the grievance process, and the date of completion in accordance with the facility's Grievance policy.

This deficient practice affected Patient #1's rights when the facility failed to resolve Patient #1's representative/mother's concerns, complaints, and grievance related to Patient #1's rights, safety, and satisfaction.

Findings included:

Complaint # TX 00234959

Review of the facility's Patient Grievance Policy/Complaint Resolution, last revised 11/2014 revealed the following, in part:

Definition of, "Grievance: a formal or informal written or verbal complaint that is made to [the facility] or [facility] employees by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to [facility's] compliance with the CMS [Centers for Medicaid & Medicare Services] Hospital Conditions of Participation (COP's), or a Medicare beneficiary billing complaint." Definition of Verbal Complaint included, a verbal complaint was a patient grievance if: "A. the complaint involves abuse, neglect, patient harm, or hospital compliance with COP's. E. Requires investigation and/or requires further actions for resolution."

Further review revealed any facility employee who receives a grievance from a patient, family, visitor or other customer will proceed as follows: "i. B. Grievances alleging patient, family member or visitor harm or those threatening legal action should be immediately forwarded to Quality Compliance Department and/or the Risk Management Department. V. Within an average of seven (7) working days from the date of the grievance receipt from the patient, family member or visitor, the Patient Grievance Committee shall, in conjunction with the General Counsel, send a written acknowledgment of the grievance to the patient, family member or visitor, which shall include the follow-up actions taken and/or the outcome of any investigation or corrective action. Such documentation will include:
A. The decision of the hospital;
B. The name of a contact person at the hospital;
C. The steps the hospital has taken to investigate the grievance;
D. The result of the grievance process; and
E. The date of completion."


Record review of the Department of State Health Services (DSHS) Complaint/Incident Investigation Narrative Report dated 03/15/16 revealed Patient #1's representative/mother alleged that her son/Patient #1 had been abused/assaulted by staff at this facility after she observed bruises and injuries to his face. Patient #1's representative/mother indicated she called and notified the facility's Behavioral Health (BH) Director of the specific allegations of abuse, neglect, and concerns with his quality of care.


Record review of Patient #1's facility electronic health records (EHR) revealed he was a 21 year-old male, presented to the facility's BH unit on 12/25/15 and was discharged on 12/30/15 to the local Police Department following an alleged physical assault on a facility staff member who was assigned his 1 to 1 supervision and caused injury. Further review of Patient #1's EHR revealed documented incidents of self-injurious behaviors of hitting self in the face, hitting head on wall, choking self, throwing self on the floor, jumping off his bed and trying to head dive. Patient #1's nose was documented swollen and very red along with facial injuries documented.

Record review of the facility's internal investigation review dated 12/30/15 for Patient #1 and titled; Assault Event (Including Removal of Patient by Police Department) revealed the following:

"There are multiple reports, verbal and written, from nursing and medical staff describing how patient engaged in violent episodes where he would attack patients and staff alike and without provocation. Patient is documented as having sustained injuries resulting from self-injurious behavior and which required medical evaluation the days prior to incident in question. Self-injurious behavior included patient hitting his own face, banging his head, running into doors and walls, and even head diving onto the floor." Patient #1's representative/mother met with the Director of BH and other facility staff on 12/31/15. During this meeting it was documented in the facility's investigation the Patient #1's representative/mother was concerned that Patient #1 was not receiving the treatment he needed.

The facility documented on 01/17/16 at 19:29; received a call from Admissions Clerk that Patient #1's representative/mother had been by the facility and started to yell telling patients not to bring their family here.

The facility documented on 01/08/16 at 10:00 AM, met with Patient #1's representative/mother and the this meeting "was the total opposite of what took place on 12/31/15" as Patient #1's representative/mother was "very angry and viewed everything said as negative. They spoke of lawyers and going to the media outlets to report the incident and even mentioned that her daughter was in Austin assumedly looking to file a complaint as they blame us for what happened to patient while in police custody and threaten to hold us accountable if something else happens to patient."

The facility's internal investigation included "Recommendations for Improvement Strategies" specifically regarding this incident event on 12/30/15. The facility's internal investigation did not include evidence that this incident resulting in allegations from Patient #1's representative/mother that her son was abused, neglected, and did not receive adequate care was addressed and resolved in accordance with the facility's Patient Grievance Policy/Complaint Resolution. In addition, there was no evidence that the facility's Patient Grievance Committee reviewed and ensured follow-up actions taken and/or the outcome of the investigation was completed with written acknowledgment sent to the patient's family member.

During an interview on 05/03/16 at 04:18 PM with the BH Director stated he met with Patient #1's representative/mother in 01/2016 and she was "very upset and blaming staff for his [Patient #1] facial injuries" during his hospitalization 12/25/15 to 12/30/15.

During an interview on 05/04/16 at 11:15 AM with Patient #1's representative/mother indicated she was concerned about her son's care received at the facility when she observed him on 12/31/15 and his face, eyes, and lips were swollen with injuries. She indicated that Patient #1 told her [representative/mother] that he was in a "fight" at the facility with a staff member and the staff "hit him." Patient #1's representative/mother indicated she reported this specific allegation to the BH Director the first part of January 2016. She indicated she reported that she wanted this complaint/grievance documented and further stated she wanted to know what happened. Patient #1's representative/mother stated she reported to the BH Director that she felt her son was "neglected;" because there was not enough staff, they did not do their job, and there was lack of care. Patient #1's representative/mother indicated she has not heard back from the facility regarding the outcome of her specific allegations or that the facility has completed an investigation regarding these specific allegations.

During an interview on 05/04/16 at 11:20 AM with the facility's General Counsel A confirmed the facility failed to follow the facility's Patient Grievance Policy/Complaint Resolution which included allegations from Patient #1's representative/mothe