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ST LUKE'S SUGAR LAND HOSPITAL
PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION
Tag No.: A0123
Based on record review and interview the governing body failed to ensure patient grievance process was followed up by the quality committee and the emergency department nursing director where 3 of 3 patients (#11,12,13) complained about the care they recieved while in the emergency department during January to present. Thus, no changes in procedure or process occurred.
Findings Include:
Record review of 3 of 3 patient grievances (patient #11,12,13), stated a root cause analysis was completed resulting in a need for policy enforcement and education of staff.
Record review facility policy "Event Reporting and Management" stated the policy is utilized for quality and patient safety improvements and is applicable to all patients within Common Spirit Departments.
Interview on 03/20/2025 at 1352 with the ED staff (#J), stated they have not had a meeting for February and were not aware of the results of the grievances.
Interview on 03/20/2025 at 1355 with the quality manager (staff #E) verified that these changes have not been shared with the quality committee or the ED nursing staff at this time.