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Based on record review and interview, the hospital failed to promptly resolve patient grievances and notify complainants of the resolution within 21 days as indicated by it's policy for 2 of 10 Grievances (Patient #14 and #15), in that, Patient #14 and #15 did not receive a resolution notification for their grievances submitted 1/09/15 and 1/14/15 respectively before the hospital's designated date for resolution and/or response as designated in it's policy. Unresolved complaint issues past 21 days were not referred to the Medical Executive or Governing Board as indicated in the hospital policy.

Findings Included

A) Patient #14
The 11/01/14 through 2/20/15 "TRMC (Texas Regional Medical Center) Grievance Log" reflected, "Received 1/9/15...Patient (#14)...Date of Service (DOS) 1/6/15...called to complain...1st Letter 1/12/15...2nd letter 2/26/15..."

The hospital's 1/12/15 letter for Patient #14's wife's grievance reflected, "(Patient #14's Wife)...You will receive a response...letter by 2/12/15..."

There was no hospital response letter sent for Patient #14's wife's grievance by the stated date of 2/12/15. The response letter was sent 2/26/15.

The hospital's 2/26/15 letter for Patient #14's wife's grievance reflected, "(Patient #14)...reviewed by the Grievance Committee...inform you that we continue to review your case and will send a response by 3/18/15."

There was no hospital resolution or letter of resolution sent for Patient #14's wife's grievance as of 3/02/15.

B) Patient #15
The 11/01/14 through 2/20/15 "TRMC (Texas Regional Medical Center) Grievance Log" reflected, "Received 1/14/15...Patient (#15)...Date of Service (DOS) 11/30/14...Patient sent letter...1st Letter 1/14/15...2nd letter 2/26/15..."

The hospital's 1/14/15 letter for Patient #15's grievance reflected, "(Patient #15)...you will receive a response...letter by 2/14/15."

There was no response letter or letter of resolution for Patient #15's grievance sent to the complainant by 2/14/15. The second response letter was sent on 2/26/15.

The hospital's 2/26/15 letter for Patient #15's grievance reflected, "(Patient #15)...continue to review your case and will send a response by 3/18/15."

There was no hospital resolution or letter of resolution sent for Patient #15's grievance as of 3/02/15.


During an interview in the conference room on 2/26/15 at 3:00 PM, Personnel #2 was asked about the Grievance Log findings for Patient #14 and #15. Personnel #2 stated, "The 2/26/15 letter will go out today to the complainants. Personnel #2 was asked what the process was for grievances. Personnel #2 stated, "We send a letter acknowledging the complaint within 7 days. We send another letter within 21 days." Personnel #2 confirmed that the letters were behind and the process was not followed. Personnel #2 was asked for the Grievance Committee Meeting Minutes. Personnel #2 stated, "We do not have any. It is completed through email mostly. For any grievance, I can pull the emails and such for review." Personnel #2 was asked if there was a resolution on Patient #14's or #15's grievances. Personnel #2 stated, "No."

During an interview in the conference room on 3/02/15 ending at 8:56 AM, Personnel #2 was asked if the grievances with unresolved issues past 21 days had been referred to the Medical Executive or Governing Board per the policy. Personnel #2 stated, "I have not made a report to Governing Board or Med Exec."

The January 2014, last revised, "Patient Complaint and Grievance Policy" required, "To establish a process for prompt resolution of patient grievances including timeframes for resolution...in addition to responding to the substance of each grievance...should also identify, investigate and resolve any deeper systematic problems...contact the patient...within 7 working days to acknowledge receipt...written notice by mail to the patient...within 7 additional business days...The entire grievance investigation should be completed within 21 days. Any unresolved grievances past 21 days will be referred to Administration, Medical Executive Committee or Governing Board as needed...A copy of the patient notification shall be attached to the investigation report and maintained in a confidential file..."

Based on record review and interview, the hospital failed to provide the patient with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 2 of 10 complaints (Patient #16 and #17) reviewed, in that, Patient #16 and #17 did not receive written notice of resolution from the hospital about their respective complaints that included the minimum requirements.

Findings Included

A) Patient #16
The 11/01/14 through 2/20/15 "TRMC (Texas Regional Medical Center) Complaint Log" reflected, "Received 11/11/14...Patient (Patient #16)...DOS 11/11/14...Mom called (after leaving ER)...wanted to file a formal complaint..."

There was no documentation for Patient #16 that a written notice of the hospital's decision that included the minimum requirements was sent to the complainant.
B) Patient #17
The 11/01/14 through 2/20/15 "TRMC (Texas Regional Medical Center) Complaint Log" reflected, "Received 12/11/14...Patient (Patient #17)...DOS 12/11/14...phone call (after leaving ER after triage.) I told her I would write it up as a formal complaint and she seemed happy with that."

There was no documentation for Patient #17 that a written notice of the hospital's decision that included the minimum requirements was sent to the complainant.

During an interview in the conference room on 2/26/15 at 3:00 PM, Personnel #2 was directed to the Complaints listed in regards to calls received post discharge and the mention of filing a formal complaint. Personnel #2 was asked if there was an investigation and/or if grievance letters were sent to the complainants. Personnel #2 stated, "No."

The January 2014, last revised, "Patient Complaint and Grievance Policy" required, "To establish a process for prompt resolution of patient grievances including timeframes for resolution...Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding the patient's care...Whenever the patient...requests...complaint be handled as a formal complaint...then the complaint is a grievance and all the requirements apply...in addition to responding to the substance of each grievance...should also identify, investigate and resolve any deeper systematic problems...contact the patient...within 7 working days to acknowledge receipt...written notice by mail to the patient...within 7 additional business days...The entire grievance investigation should be completed within 21 days. Any unresolved grievances past 21 days will be referred to Administration, Medical Executive Committee or Governing Board as needed...A copy of the patient notification shall be attached to the investigation report and maintained in a confidential file..."

Based on observation and interview, the hospital failed to safeguard the confidentiality of electronic and paper patient records, in that, during the tour of the hospital on 2/26/15, one of 8 nursing computer/carts (Cart #5) was left unattended, open to a patient chart and had face up nursing report sheets with patient information on the desk of the cart.

Findings Included

During a tour of the hospital on 2/26/15 ending at 10:14 AM, Personnel #1 and the surveyor observed the patient care and service areas of the hospital. There were nursing desks and computer/carts approximately halfway down each of the hallways. One computer on a cart in the Medical Surgical Hallway labeled, "Room 223 - 242" had been left unattended, opened to a patient chart. The desk of the computer/cart contained more than 1 nurse report sheet, face up with patient information on the sheets.

During an interview on 2/26/15 ending at 10:14 AM, Personnel #1 was present when each of the above findings was found and she was asked to verify the findings. Personnel #1 confirmed the findings. Personnel #1 stated, "Yes. They should logout (of the computer)."

The November 2009 "Patient Rights and Privacy" required, "The patient rights include...to confidentiality of your clinical records..."