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1307 CLEVELAND STREET

FRIONA, TX 79035

PATIENT CARE POLICIES

Tag No.: C1008

Based on record review and interview, the facility failed to develop, biennially review, and follow policies related to grievance procedures.

The findings include:

A review of patient #17's chart revealed the patient's daughter complained to staff #2 about treatment-related concerns via phone on approximately 1/10/21. The facility failed to provide the surveyor with a written investigation report and a written decision determination report. Staff #2 stated, "Yes, I did speak with her, [I] but did not write anything up" after the conversation.

Facility's grievance policy "Parmer County Community Hospital- Section 504 Grievance Procedure (Patients, Visitors, and Employees)" procedure steps III, IV and V read as follows:

III. " The Administrator shall conduct such investigation of a complaint, as may be appropriate, to determine its validity. These rules contemplate informal but thorough investigations, affording all interested persons and their representatives, if any, an opportunity to submit evidence related to a complaint.

IV. The Administrator shall issue a written decision determining the validity of the complaint no later than 30 days after its filing.

V. The Coordinator shall maintain the files and records relating to complaints filed hereunder. "

In an interview, held on 7/1/21 at 1205 pm in the hospital conference room, staff #2 (responsible for the facility's internal grievance procedures) stated, "I don't know when this policy was updated last. I have not been doing written follow up or sending a letter" of determination of validity to the complainant. Staff #2 validated the facility's failure to follow the facility's grievance policy and procedure, stating, "Look, I told you two times now that I haven't been doing this. We will have to review this policy."