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Based on interview and record review, the facility failed to provide the Patient's Representative with a written notice of decision that contained the steps taken on behalf of the Patient to investigate the grievance, the results of the grievance investigation, and the date of completion for 1 of 1 Patient's reviewed (Patient #1) with a grievance lodged by his representative on 1/26/18.

Specifically, as of 10/04/18, Patient #1's representative had not received resolution of his grievance, and 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 investigation, and the date of completion in accordance with Federal Grievance policy requirements.

This deficient practice affected Patient #1's rights when the facility failed to communicate in writing the outcomes to Patient #1's representative regarding the concerns, complaints, and grievance expressed on behalf of Patient #1's rights, safety, treatment, and satisfaction.

Findings included:

Complaint # TX 00293765

Review of the facility's Grievance Complaint Process Policy, last revised 11/2014 revealed the following, in part:
Patient Grievance/Patient Complaint is defined as a written or verbal concern (when verbal concern about patient care is not resolved at the time of the concern by staff present) by a patient or patient's representative, regarding the patients care, treatment, abuse or neglect, issues related to the facility's compliance with regulatory agencies



Record review of the Department of State Health Services (DSHS) Complaint/Incident Investigation Report dated 08/10/18 revealed Patient #1's representative submitted a complaint/grievance to DSHS and expressed concern that the family was not notified of the death until 1/25/2018 amongst other concerns. On 1/26/2018 @ 4:49pm the patients' representative telephoned the management of the hospital and expressed concern that, the family was just notified that the father(patient) passed away a few weeks ago. Wanted to know why they are now being notified. He was informed that we would look into and would get back to him. This telephone complaint was documented on the facility Complaints/ Concerns/Grievance Worksheet dated 1/26/2018 @ 4:49pm.




During an interview on 10/4/18 at 12:20pm with the Regional Lead of Patient Experiences/ Patient Advocate revealed, that they received the phone call from the patient's representative on 1/26/2018, they explained the patients' representative what had occurred with the patient, and the representative seemed satisfied with that, there was no written letter sent to complainant by the patient advocate.


During an interview on 10/4/18 at 12:45PM AM with the Director of Performance Improvement/Risk Management revealed and also confirmed that Risk Management had not sent a response in writing regarding the results of the investigation to Patient #1's representative nts required under federal and state regulations.