HospitalInspections.org

Based on observation, interview and record review, the facility failed to enforce policy to ensure patient rights in 1 of 3 sampled patients. Patient #1

Findings:

Patient #1

An interview was made by the Surveyor with Patient #1 by telephone on 03/11/2015 at 4:20 p.m. revealed that she verified the contents of the complaint details filed to the State Agency as stated on Intake #TX00211697.

Review of Patient #1 closed Medical Records on 03/12/2015 revealed that she was admitted to the facility on 09/24/2014 due to labor complaint, presented with contractions. Delivered a baby boy on 09/25/2014 via Caesarian Section due to ' arrest of descent ' . Patient #1 was discharged on 09/29/2014, while the baby boy was discharged on 10/08/2014.

Review the facility ' s complaint log revealed that Patient #1 filed complaint on 11/20/2014 stated " Patient with concern that the L&D nurse caring for her caused her baby to have to spend 12 days in the NICU " . Final letter due date on 01/04/2015; however, 2nd letter mailed to complainant on 02/18/2015 via Certified mail. The facility re-sent the letter to the complainant on 03/06/2015 since it came back to the facility on 03/05/2015. The complaint status is considered closed.

During an interview made on 03/12/2015 at 3:25 p.m., with the Risk Prevention Coordinator (6) the Surveyor verified if there was a mailed letter to the complainant, and she said " Yes, the 2nd letter was certified and it has tracking number, but she did not get it. So I re-sent it via regular mail this time, using the same information in this letter. " The Surveyor verified if she called patient #1 to notify delay in response, and she said " No, because from the start, I already spoke with her in December 2014 and I explained the process, that every response will be sent by mail. I had to wait for our Physician to give us his review feedback about this case so we could mail that letter. It was completed 1st week of February, then so we mailed it using the same letter. " Risk Prevention Coordinator (6) provided a copy of the letter mailed to Patient #1 that revealed mailing address.
Observation made by the Surveyor about the certified letter mailed to Patient #1. The address was not the same address in patient's profile.
During an interview on 03/12/2015 at 03:35 p.m. with the Facility ' s Vice President (1), the Surveyor notified her that the mailing address written on the letter is not the same address of Patient #1 in file as this was the same address that they used; she said " Yes, you are right. It was to a different address, we will make sure to mail letters to the right recipient next time. "

During an interview on 03/13/2015 at 08:45 a.m. with the unit staff nurse (9), the Surveyor verified when did she 1st hear this complaint of Patient #1 about her nursing care, she said " For sure it was after when I came back from a vacation in October 2014. My manager told me about it. "

During an interview on 03/13/2015 at 10:20 a.m. with Physician staff (7), the Surveyor told him there was no written statement about the Patient #1 as part of the facility response to grievance after he reviewed her medical case; he said " Yes, I did the review. I wondered this patient filed complaint 2 months after she was discharged. None, there is no report made, nobody asked me to create one after reviewing it. "

Review of the facility ' s policy about Customer Feedback Supersedes Policy Patient Complaint # 900.2218 on page 4 items 4, 5&6 " Coordination of the investigation, including review and evaluation of follow-up response and preparation and communication of the final assessment. Monitor response from director/manager to be within 45 days from date of the original complaint. Patient advocate will send follow-up letter to complainant. When appropriate the Director/Manager may contact the complainant by phone, which may resolve the issue and therefore a follow-up letter is not necessary. {Sec C item #3} Resolving issues in a time fashion and communicating findings of the investigation the risk module. Documentation will include a thorough description of the incident, as well as how and/or what corrective actions were taken. "