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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/spouse on 12/27/17.

Specifically, As of 5/09/18, Patient #1's representative/spouse had not received resolution of his grievance, or 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 the facility's Grievance policy.

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

Findings included:

Complaint # TX 00282643

Review of the facility's Patient Complaint and Grievance Policy, last revised 05/2015 revealed the following, in part:
A written complaint was always a grievance, whether from a patient or their representative.

Procedures: Patient Grievance, D. Each issue defined as a Grievance will be followed up with a written notice of decision prepared by the Director of Quality/Safety/Risk and approved by the Grievance Sub-Committee. The written response will contain the following elements:
1. Date of receipt of Grievance,
2. The name of the hospital contact person for patient follow up if needed,
3. The steps taken to investigate,
4. The results of the investigation, and
4. The date of completion.

E. A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf.


Record review of the Department of State Health Services (DSHS) Complaint/Incident Investigation Report dated 01/10/18 revealed Patient #1's representative/husband provided written complaints/grievance to the DSHS and to the management of the hospital. Patient #1's representative/husband made allegations the facility prescribed medications to Patient #1 with a known drug reaction history to Codeine; which resulted in an adverse drug reaction prompting Emergency Management Services (EMS) being called.

Further review of the complaint/grievance indicated Patient #1's representative/husband indicated a copy of summary complaints were shared with the facility's Director of Quality on 12/27/17 and as of 1/10/18; stated, "To date, we have had no response."


Record review of the facility's Grievance Log revealed on 12/20/17 Patient #1's representative/husband stopped at the quality administration to speak with the quality department personnel and stated concerns about Patient #1's discharge instructions to his wife, and a complaint about the physician bedside manners. Further review revealed, "Husband wrote an extensive narrative on the events above." On 12/27/17 Patient #1's representative/husband met with quality department personnel about another complaint regarding medications prescribed.


During an interview on 5/9/18 at 11:30 AM with the Director of Quality confirmed the Risk/Quality department received a written complaint/grievance by Patient #1's representative/husband the second time he made contact with the quality administration on 12/27/17. The Director of Risk also confirmed the quality department had not sent a response in writing regarding the results of the investigation to Patient #1's representative/husband to include; a written response of the required elements of the policy stated above. The Director of Quality stated she thought the complaint/grievance had been resolved during the 12/27/17 meeting.