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Based on record review and interview, facility failed to ensure effective operation of its grievance process. Facility failed to follow its established grievance process in investigating patient ' s grievance in 1 of 10 patients ' sample relating to grievances (Patient ID# 30). This failed practice prevented effective resolution of the grievance.

Patient ID# 30 alleged that he was restrained for intramuscular (IM) medications on 5/11/13 during his stay in the hospital and his back was injured during the process.

Review of internal investigation of the complaint revealed that the grievance was not investigated through the appropriate Quality Assurance Performance Improvement QAPI process as required by facility ' s policy.

Review of facility ' s policy titled " The Patient Complaint and Grievance Policy " dated 3/30/06 read " When grievances involving quality of care are received by the Patient/Customer Relations Department, the grievance will be entered into the Electronic Incident Reporting System, and forwarded immediately to the Quality Management Department, which will evaluate the merits of the grievance and make determinations and recommendations for resolving it as required by the Patient Safety Plan approved by the Board of Managers. "

Interview with Staff ID# 72, Patient Advocate on 7/11/13 at 10:10am in conference room, she stated that patient called in a complaint on 5/15/13 to Customer Relations Department (CRD) and stated that he was restrained for IM medications while in the hospital and hurt his back, he wanted his back examined and the hospital to pay for the treatment. Patient was informed that his complaint will be investigated but a determination for treatment cannot be made at that time. He was instructed to go to ER for evaluation if necessary. He decided to go to LBJ; facility ' s other campus, and requested a bus pass which was provided to him. Complaint was forwarded to the Behavioral Health Department for investigation. An MRI was done at LBJ and the result was inconclusive of the time of injury. Based on findings, a letter was sent to the patient that his complaint was unsubstantiated. Staff added that patient had expressed his dissatisfaction with the resolution when he was contacted over the phone. Staff acknowledged that complaint was not referred to Quality Management Department (QMD).

Interview with Staff ID# 34, Director Behavioral Health, on 7/10/13 at 2:00pm in the unit psychiatrist office, she stated that patient ' s complaint was investigated at the department level when received from the CRD, and after interview with staff, review of patient ' s chart and result of x-ray from LBJ, the complaint could not be substantiated and a follow up letter was sent to patient to that effect.

Interview with Staff ID# 73, Risk/Quality Management on 7/11/13 at 9:20am, he stated that he was not aware of the complaint prior to this survey. He explained that the facility ' s grievance process requires that when a grievance is received by the CRD relating to quality of care, it is immediately referred to the QMD for investigation and the staff of CRD has been instructed to also notify him over the phone. He added that this complaint should have been immediately forwarded to QMD and this was not done.

Staff ID# 3, Ben Taub Administrator on 7/12/13 in the conference room also acknowledged that the facility failed to follow the appropriate process in investigating the complaint.

Based on record review and interview, facility failed to ensure effective operation of its grievance process. Facility failed to follow its established grievance process in investigating patient ' s grievance in 1 of 10 patients ' sample relating to grievances (Patient ID# 30). This failed practice prevented effective resolution of the grievance.

Patient ID# 30 alleged that he was restrained for intramuscular (IM) medications on 5/11/13 during his stay in the hospital and his back was injured during the process.

Review of internal investigation of the complaint revealed that the grievance was not investigated through the appropriate Quality Assurance Performance Improvement QAPI process as required by facility ' s policy.

Review of facility ' s policy titled " The Patient Complaint and Grievance Policy " dated 3/30/06 read " When grievances involving quality of care are received by the Patient/Customer Relations Department, the grievance will be entered into the Electronic Incident Reporting System, and forwarded immediately to the Quality Management Department, which will evaluate the merits of the grievance and make determinations and recommendations for resolving it as required by the Patient Safety Plan approved by the Board of Managers. "

Interview with Staff ID# 72, Patient Advocate on 7/11/13 at 10:10am in conference room, she stated that patient called in a complaint on 5/15/13 to Customer Relations Department (CRD) and stated that he was restrained for IM medications while in the hospital and hurt his back, he wanted his back examined and the hospital to pay for the treatment. Patient was informed that his complaint will be investigated but a determination for treatment cannot be made at that time. He was instructed to go to ER for evaluation if necessary. He decided to go to LBJ; facility ' s other campus, and requested a bus pass which was provided to him. Complaint was forwarded to the Behavioral Health Department for investigation. An MRI was done at LBJ and the result was inconclusive of the time of injury. Based on findings, a letter was sent to the patient that his complaint was unsubstantiated. Staff added that patient had expressed his dissatisfaction with the resolution when he was contacted over the phone. Staff acknowledged that complaint was not referred to Quality Management Department (QMD).

Interview with Staff ID# 34, Director Behavioral Health, on 7/10/13 at 2:00pm in the unit psychiatrist office, she stated that patient ' s complaint was investigated at the department level when received from the CRD, and after interview with staff, review of patient ' s chart and result of x-ray from LBJ, the complaint could not be substantiated and a follow up letter was sent to patient to that effect.

Interview with Staff ID# 73, Risk/Quality Management on 7/11/13 at 9:20am, he stated that he was not aware of the complaint prior to this survey. He explained that the facility ' s grievance process requires that when a grievance is received by the CRD relating to quality of care, it is immediately referred to the QMD for investigation and the staff of CRD has been instructed to also notify him over the phone. He added that this complaint should have been immediately forwarded to QMD and this was not done.

Staff ID# 3, Ben Taub Administrator on 7/12/13 in the conference room also acknowledged that the facility failed to follow the appropriate process in investigating the complaint.