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Based on review of documentation and interview with staff, it was determined the facility failed in its resolution of the grievance as evidenced by the complainant did not receive written notice of the resolution.

Findings included:

A review of facility policy# PC-41 entitled, "Complaints, Patients, and Families" revealed "Purpose: To provide a mechanism to receive and respond to patient and/or family complaints concerning quality of care of any other issues." Further review stated, "1.b. Complaints may be via telephone, verbally, or in writing." The policy also stated, "3. Each patient or family making a significant complaint will receive a response from the respective department and/or administration."

A review of policy # HW-20 entitled, "Complaint/Grievance Resolution process," revealed "The Director of Risk Management shall operate and maintain the hospital's grievance mechanism designed to process and resolve patient complaints and formal grievances while maintaining a comprehensive record of complaints presented to Dallas Regional Medical Center." The policy also stated, "A written complaint is ALWAYS considered a grievance, whether from an inpatient ...or their representative regarding the patient care provided." The policy also stated that an Email or fax was considered "written." In the section "Receipt of Complaints" stated "B. 2. Grievances require written notice (response) to the patient within (7) days. The written response will contain the name of the hospital contact person and identify the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion ...If the grievance is not resolved within seven (7) days and if investigation is not complete or if corrective action is still being evaluated, the hospital's response should address that the hospital is still working to resolve the complaint and that the hospital will follow-up with another written response within (7) business days..." Further review revealed "C. 1. Upon receipt of complaint from patient or patient representative, the department receiving shall date the complaint and attach to a Patient/Customer Feedback Form ...5. Identify appropriate response to the patient ...8. Risk Management/Administration designee to provide oversight to all written letter responses."

In multiple interviews with staff member #3, on 3/12/2012, it was confirmed patient #1 did not receive a written notice from the facility regarding the grievance filed. Staff member #3 stated the facility was not aware a grievance was filed until the surveyor asked the staff member #3 if a grievance was received by the facility. The facility located the grievance on 3/12/2012 and it was determined the grievance was reported to the facility on 12/11/2011.