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Based on record review and interview, the facility's policy for patients' rights failed to include accurate information regarding the resolution of patient complaints and grievances concerning the quality of care.

Specifically, the facility's patient rights policy did not include the correct phone number and address for submitting a complaint or grievance to the appropriate state health care regulatory agency that has authority and licenses the facility; Texas Department of Health and Human Services Commission (HHSC) at (888) 973-0022.

Findings included:

Review of complaint TX00469884 received on 9/5/23 on behalf of Patient #1 indicated the complainant attempted to file a grievance with the facility, however, she had not been able to reach anyone.

Review of the facility's policy titled, Patient's Rights and Responsibilities last reviewed 05/2021 indicated on page 2, number 16. "Resolution of complaints and the right to submit a complaint by contacting any charge person, supervisor, department head or member of the medical staff or administration, or by calling the Texas Medical Foundation, 1-800-725-8315, 901 Mopac Expressway South, Austin, TX 78746."

On 10/23/23 at 2:55 PM, this Surveyor called the number in the policy, 1-800-725-8315 with the interim Chief Nursing Officer (CNO) present. The original message was in Spanish and then the message went on to say I was eligible for a free medical alert device.

During an interview on 10/23/23 at 3:00 PM with the Interim Chief Nursing Officer after review of the policy and the phone call to 1-800-725-8315 stated she was not sure where that number or information came from that is in the facility's Patient's Rights policy.

Further review of the Patient's Rights and Responsibilities policy; and in addition, page 2, number 9. indicated "Access protective services by contacting Social Services at 350-7795." There was not an area code provided for this number or details for this Social Services number.