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Based on interview and record review, the facility failed to fully investigate and document its process for addressing grievances regarding clinical care issues/provider decision-making and issues regarding discharge care coordination/post-acute supplies that were arranged. (Patient ID# 1).

Findings included:

HHSC Intake received 8/4/23 via telephone. Complainant stated the facility negligently discharged her family member from hospital too soon and with inappropriate oxygen equipment. She stated as a result complaint patient ID #1 had passed away.

Telephone Interview with Complainant for HHSC Intake TX on 10/2/23 at 08:55 am. She re-stated that Patient ID#1 had been "very ill" and admitted to ICU and had emergency surgery. She stated that she had been discharged too early from the hospital negligently, that oxygen equipment which was provided by hospital was not delivering continuous oxygen and she believed this contributed to her unexpected death within two days. She stated she had filed a complaint with hospital but had been told "they conducted a review" and there was nothing identified as contributing. She stated they did not believe this assessment because they had been told by EMS that she was on wrong oxygen mask and source.

Record review of electronic grievance and complaint log dated February 1, 2023 to 10/3/2023 revealed Patient ID#1 with grievance entered 7/12/23 with category "Care Management."

Record review of electronic grievance and complaint entry related to Patient ID #1 revealed:
7/14/2023 08:29 am grievance received by Patient Relations Staff ID #77 via a telephone call from Patient ID#1 family member. The grievance log record stated "(Family member) alleges pt. was discharged without further evaluation of a (specific condition)." The grievance alleged the patient was discharged home too early, had concerns about home health nursing staff coordinated by the hospital, and that the oxygen sent to patient was wrong. Complainant notified the facility of Patient ID #1 death. Complainant expressed desire to avoid same experience for other patients and families.

7/14/23 10:43 am - Entry by Staff ID # 76, Patient Relations Representative, "Mailed initial letter." Copy of letter dated 7/14/2023 and reviewed. The letter stated "these issues are being addressed and you will receive a written response upon completion of this review process or within 30 business days."

7/18/23 10:41 Correspondence between unit staff and patient relations team included a timeline of patient's clinic course and discharge which was prepared by 6West nurse manager, Staff ID #59. In addition, correspondence between patient relations and home health coordinator, Staff ID # 69, stated "our staff/facility understands the importance of identifying discharge needs to ensure a safe discharge. There was no discharge barriers identified when home health was ordered."

7/27/23 The facility mailed a closure letter dated 7/19/23 and prepared by Patient Relations Staff ID #77 which stated the facility "conducted a review." It stated "Based on clinical assessment, it was determined that she had reached a stable point of discharge and transition that did not require inpatient hospitalization. Our case management department was able to coordinate the after-care plan thoroughly to ensure her needs are met while at home. Our nursing team did reach out and spoke with you and advised accordingly."

8/4/23 at 2:11 pm, Patient Relations Staff ID #77 electronic notes stated Patient ID #1 "(family member) reached out upset about our review she asked why the clinical team did not reach out to the family and listen to their concerns. I did inform her and reminded her that we spoke and she did share her concerns with me and I did explain to her our process an agreed with formal grievance. She then stated well I do not agree with the review you guys killed my mom discharged her home when she was not stable enough with wrong equipment ..."

8/8/23 at 08:21 am Patient Relations Staff ID #77 entered an email obtained from Staff MD #79 which stated "Good morning, reviewed the case, regarding patient's (specific diagnosis). He expressed discussing the case with staff Surgeon ID #68 pertaining to findings seen on CT scan the findings. Surgeon Staff ID #68 noted this was an expected finding after intra-abdominal surgery and no further intervention was necessary. Physician ID #77 stated "Medical care was appropriate in this case."

Record review of facility "Patient Rights" form, revised 08/2020, stated "You have the right to register complaints about care or treatment and receive a response to those complaints by informing your direct caregiver, management or by contacting the Hospital's Patient Relations Department."

Record Review of facility's "Patient Complaints and Grievances Procedure", last reviewed 6/3/2022, stated "Action: 5. Document grievances in the hospital approved electronic tracking tool.. and refer to appropriate personnel to review and investigate ... 7. Department leadership will investigate the grievance including, as appropriate, clinical reviews and staff interviews."

Interview with Staff ID # 79, Director of Hospital Medicine service, on 10/3/23 at 2:05 pm. He stated he had received an email asking him to review Patient ID #1's case related specifically to (one post-operative clinical diagnosis). He stated he was not aware of allegation in grievance, which included improper/precipitous discharge or improper oxygen equipment. He stated he focused specifically on the (post-operative clinical diagnosis) aspect of complaint. He had not reviewed patient's clinical status at discharge to determine if patient met criteria for discharge, had not reviewed specific orders related to post-acute services and was not aware of the order/use of oxygen conserving device. He stated he does complete comprehensive case analyses when asked, but he was unaware of full issues/allegations and therefore it was not completed in this case.

Interview with Staff ID # 51, Quality Manager, on 10/3/23 at 2:45 pm. She confirmed that no formal quality case analysis had been performed. She stated that she "checked with the medical staff office and no evidence of peer review, clinical case analysis or mortality review had been conducted." She confirmed there was no variance entered.

Interview with Staff ID #58, Patient Relations director on 10/3/23 at 1:35 pm. She confirmed there was no further written or verbal correspondence with the complainant provided by the facility after the initial closure letter dated 7/19/23. She confirmed the grievance investigation process should include investigation for all elements of the grievance.