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Based on surveyor record review and interviews, the facility failed to establish and enforce a clearly explained procedure for submitting a patient's or a patient representative's written or verbal grievance to the hospital. The findings include:



1. The complainant called the patient relations department to file a complaint regarding the lack of patient care, and the lack of monitoring that she believed was causing patient #1 harm. The complainant stated, "I think they caused my father to die from an infection and die earlier than he should have."

2. The facility's representatives failed to identify the verbal complaints of poor care and allegations of neglect from patient #1's representatives as a grievance.

3. Surveyor review of the Complaint Log for February 2022 filed by the patient relation specialist [patient advocate] found the following entries with unknown resolution process for a complaint of potential verbal abuse [patient #11] and patient #19's complaint of poor care that was to be "escalated." The surveyor review did not find evidence of patient # 19's complaint escalation.

a. Patient #11's complaint was documented as follows:
"The patient wants to file a complaint about his experience in the emergency department. The patient stated his IV saline missed the vein, and he alerted the nurse, but he didn't seem to care. . . The patient overheard his nurse make a derogatory statement about him. Patient relations apologized for the poor experience. Patient Relations will notify the department managers to review the patient's concern." Event report date 2/17/2022. Resolution/Closure 2/17/22.
b. Patient #19's complaint was documented as follows:
"The patient's wife submitted a patient relations form stating the patient did not receive good care during his admission. Patient relations notified the department manager of the wife's concern. Patient relations apologized for the poor experience. Patient relations informed the spouse we will have her concerns escalated." Event report date 2/7/2022. Resolution/Closure date 2/7/2022.

4. BSW Patient Complaint Process flowsheet, dated 2/8/2022, gives direction for complaints as follows [in part] "Is it a quality of care issue if yes Refer to PCE [abbreviation per document] within 24 hours and remain patient relations' contact for PR/PCE then enter as an incident in RisKonnect; initiate appropriate contacts; Document actions; & maintain compliance with guidelines then Provide acknowledgment (verbal or written) informing patient/rep of review process and timeframes, then When PCE review is complete, Draft closure letter per BSW policy & submit through review/ approval process with PR VP for final approval, then Scan in signed closure letter and attach to RisKonnect incident to mailed regular & certified mail to patient/rep; Enter/Update Contacts and Notes; Close incident."

5. During a personal interview on 3/7/22 at 1250, staff #2 stated, "No, I do not contact the patients or families [complainants] again to see if the issues have been resolved. I go with what the unit managers tell me. If they [the unit managers] say it is resolved, I close it out in the computer. There isn't any written protocol or guidance that determines when a quality-of-care issue is escalated to a grievance. I use my judgment to decide."

6. CMS guidelines read [in part], "A verbal complaint is a patient grievance if: it cannot be resolved at the time of the complaint by staff present; Is postponed for later resolution; Is referred to other staff for later resolution; Or, requires investigation and/or requires further actions for resolution. Any verbal or written complaint regarding abuse, neglect, patient harm, or hospital compliance with CMS COP" to be classified as a grievance.


7. Baylor Scott and White Round Rock's Patient Complaints and Grievances policy reads [in part], "Grievance - A formal or informal written or verbal Complaint that is:

Made to BSWH by a patient, or the patient's representative; and,

Regarding the patient's care (when the Complaint is not resolved at the time of the Complaint by staff present), abuse or neglect, or issues related to the facility's compliance with the Centers for Medicare and Medicaid Services ('CMS") Conditions of Participation ("CoPs").

Requested by the patient, or the patient's representative, to be handled as a "Grievance."


8. During a phone interview on 3/7/22 at 1520, staff #4 stated, "The patient relation specialist is empowered to make their own decisions as to when they escalate a patient compliant into a grievance." When asked what type of training the patient relation specialist receives to validate that the decisions being made by the patient relation specialist are correct, staff #4 stated, "I'm not sure what type of training they receive. That's a good question."


Findings were validated by staff #3 on 3/7/22 at 1530. Staff #3 stated, "I guess we don't know if a complaint is resolved if we are not going back to speak with the patient or family again before the complaint is closed out."