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Based on interview and record review the facility failed to ensure 10 (# s' 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) of 10 patients received an accurate notice for the complaint hot-line of the State Regulatory agency.
This deficient practice had the potential to affect all patients receiving care in the hospital.
Findings include:

Review of a patient admit folder revealed a form named "Complaint/Grievance Management" which had the following information:
"In the event that were unable to resolve your concern, you may contact:
The Texas Department of State Health Services at 1-888-963-7111"
Review of charts revealed the following patients/or representatives acknowledged receiving the above incorrect complaint number:
Patient #1 admitted 05/18/13;
Patient #2 admitted 05/12/13;
Patient #3 admitted 05/19/13;
Patient #4 admitted 05/19/13;
Patient #5 admitted 05/14/13;
Patient #6 admitted 05/13/13;
Patient #7 admitted 05/12/13;
Patient #8 admitted 02/13/13;
Patient #9 admitted 03/27/13;
Patient #10 admitted 04/22/13.
During an interview on 05/21/13 the CNO was shown the complaint number written on the admit sheets. The CNO reported the number of 1-888-963-7111 was what they were using and she did not know they had the wrong number. The same number was used on their posting on the monitors at the elevators.

Based on interview and record review the facility failed to ensure timely complaint acknowledgement and resolution notification in 4 ( # s' 11, 12, 13 and 14) of 4 complaint\grievances.
This deficient practice had the potential to affect all patients receiving care in the hospital.
Findings include:

Review of the policy "Patient Complaint/Grievance" revised 02/09 revealed the following grievance process:
"All grievances will be forwarded immediately to the CNO or designated individual.
The CNO will direct the grievance to the appropriate individual (s) for their investigation and report.
The investigator will gather the data as necessary; will gather all key persons involved to resolve the grievance.
The patient, family or patient representative who filed to grievance will receive a written response within an average of seven (7) working days .... The written response will include the individual 's name, phone/fax number, steps taken in the investigation, the results and actions, and date of completion. The CNO will be responsible for submitting any written responses.
If the investigation will not complete within seven (7) working days, a letter will be sent to the patient, family or patient representative stating that the organization is still working to resolve the grievance and a written response will be forwarded as soon as possible."

Review of the complaint and grievance file revealed the following:

* Patient #13 's family member made a complaint on 05/12/13 that her child needed a computerized tomography (CT) head test. The "CT tech was rude and mean to her child during the exam." Documentation on the form dated 05/12/13 and 05/20/13 revealed request for resolutions on the complaint. There was no documentation the family was notified of a resolution.
* Patient #12 made a written complaint on 01/07/13 revealing he waited in the ER for 17 hours for a bed. "Arrived at 1730, and was not told until after midnight that he was going to be admitted and all beds were full. This was after his wife went to the nurses ' station upset and ready to leave with the patient. They both reported than no one told them anything. He complained of asking for food, meds, etc. and was told he could not have anything. Pt. said it was very poor communication."
* Patient #11 made a complaint about care and not receiving antibiotic therapy on 01/08/13. There was documentation on the complaint report of an acknowledgment letter being sent out to the complainant on 01/15/13 and a follow-up (completion) letter on 01/24/13. Review of the actual letters revealed the completion letter was dated 01/28/13. There was no completion letter sent 01/24/13.
* An undated complaint letter revealed a family member made a verbal complaint about Patient #14 on 12/19/12 to the CNO. There was documentation in the letter that the CNO advised the family member to put their complaints in writing since they did not have any forms for accident reports or complaints. The complaint involved rough treatment by staff, doctor visit not being timely, and refusal to transfer Patient #14 to another hospital. There was no documented date of when the complaint letter was written or received by the hospital. An acknowledgement letter from the CNO was sent to the family on 01/29/13 (over a month after the initial verbal complaint). There was documentation in the acknowledgement letter that a report would be sent to the family after completion of the investigation. No completion letter was provided to the surveyor.

Review of the complaint/grievance log for the time period from 11/2012 to 05/2013 revealed creation dates logged for each complaint.
During an interview on 05/20/13 at 4:29 p.m., the CNO reported the creation dates were not the actual dates she received the complaints from the patients or family members. The dates documented were when she actually logged the complaints in the computer. The CNO reported the initial letter was supposed to be sent out within 7 days, but that does not always happen. She did not always get the complaint back from the different departments timely.
During an interview on 05/21/13 at 9:15 a.m., the CNO reported their new complaint system was put into effect on 12/01/12. The new system involved the complainant or staff going online and completing a complaint form. Sometimes if complaints were received and not written down they would just "vaporize." The CNO was shown the complaints found in the log and reported she knew they had problems. The complaint on Patient #13 dated 05/12/13 had just been done on last night (05/20/13) and the one on Patient #12 dated 01/07/13 still had not been completed. The CNO reported she had just found out about the complaints being incomplete on 05/20/13 when the surveyor requested the information. She did not know when they received the written complaint on Patient #14.