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Based on interview and record review, the facility failed to follow its established grievance policy.

The facility failed to provide a 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. [Citing Patient ID # 9].

Findings included:

TX00431540

Record review of facility policy titled: "Patient Complaint and Grievance Management", dated July 2022, showed:

-Grievance: a formal or informal written or verbal complaint that is made by a patient, regarding a patient's care when the complaint is not resolved by staff present;

-All verbal or written complaints regarding abuse, neglect, or patient harm...are considered Grievances for the purposes of these requirements.
-The Patient Advocate or designee responds to the Grievance with written notice to the patient or their representative within seven (7) days of receipt of the Grievance. The notice includes:

1. The name of the Hosptial contact person;
2. The steps taken on behalf of the patient to investigate the Grievance;
3. The results of the Grievance process; and
4. The date of completion.

-If the Grievance is not able to be resolved within seven (7) calendar days, a written acknowledgment shall inform the patient that the hospital is still working to resolve the Grievance, and that the hospital will follow-up with a written response within 30 calendar days.
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Record review on 10/17/2022 of the facility's Incident Log, dated August 2022, showed listings for two(2) incidents, dated 8/17/2022 and 08/18/2022 related to Patient ID # 9. These two(2) incidents were categorized by TYPE, as : "Behavioral;" the other as "Other Patient Care."

On 10/17/2022 , facility documentation related to the investigation of these two incidents was reviewed with Staff K, Market Quality Director.

Record review of facility investigation of these variances showed on 08/17/2022 Patient ID # 9 alleged that a night nurse was aggressive and physically threatening with her when he attempted to put a Bilevel positive airway pressure [BiPAP ] oxygen mask back on her face. Further review showed the facility conducted a timely and thorough investigation. The facility was unable to substantiate the allegations. The investigation was closed on 08/31/2022.

During an interview on 10/17/2022 at 2:30 PM with Staff K, she stated there was no documentation to show that Patient ID # 9 had been sent a letter that informed her of steps taken and outcome of the investigation.

During a telephone interview conducted on 10/17/2022 with former Patient ID # 9, she stated hospital staff spoke with her about her concerns while she was still in the hospital. She went on to say she never received any written correspondence or telephone calls from the hospital related to the outcome of the investigation.