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Based on interview and record review, the facility failed to provide for 1 of 1 Patient's reviewed (Patient #1) with a written notice of decision following Patient #1's representative/daughter's written complaints and grievance dated 11/27/14 regarding the quality of care Patient #1 received on 02/01/14.

Specifically, as of 04/30/15, Patient #1's representative/daughter had not received resolution of her grievance, or a written response from the facility with adequate information to include: steps taken on behalf of Patient #1 to investigate the written grievance, the results of the grievance process, 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 resolve Patient #1's representative/daughter's written concerns, complaints, and grievance related to Patient #1's rights, safety, and satisfaction.

Findings included:

Complaint # TX 00212938

Review of the facility's Patient Complaint and Grievance Process Policy effective 06/14/2012 revealed the following, in part:

B. A written complaint was always a grievance, whether from a patient or their representative.
C. Patient complaints that become grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding their patient care after being discharge.
E. Patients filing a verbal or written grievance will receive a written response from the hospital.
F. If the grievance will not be resolved, or if the investigations will not be completed within 7 days, the patient or the patient's representative is to be informed in writing that the hospital is still working to resolve the grievance and that the final response will follow within 21 days.
J. The written response to the patient is to include:
1. The name of the hospital contact person,
2. The steps taken on behalf of the patient to investigate the grievance,
3. The results of the grievance process, and
4. The date of completion.
The response does not need to include an exhaustive explanation of every action taken to investigate or resolve the grievance but must provide adequate information to address each item.
K. The hospital may use additional strategies to resolve a grievance, such as meeting with the patient and his/her family, negotiation/mediation, or other methods it finds effective. However, the hospital must still provide a written response to the grievance.
L. 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 03/18/15 revealed Patient #1's representative/daughter mailed written complaints/grievance to the Patient Safety Officer (PSO) dated 11/27/14. Patient #1's representative/daughter stated she "would like to know why so many mistakes occurred that day [02/01/14], namely by [Physician #1], which contributed greatly to my mother's death. Patient #1's daughter's letter indicated, "my family would like the following issues addressed by [the facility], and [Physician #1].
1. Who failed to call the heart alert or heart code?
2. Why did [Physician #1] ignore or fail to properly interpret lab reports?
3. What was The Patient Care Plan for my mother?
4. Did [Physician#1] Intubation drug choices stop the patient's heart?
5. Why only a fourteen minute heart code?
6. Why did no one tell my father my mother was dying?
7. Why was the family's request for an autopsy denied?"

Further review of the complaint/grievance indicated Patient #1's representative/daughter asked to be present during the investigation of this matter, but was denied the opportunity. Patient #1's representative/daughter requested resolution in this matter by having the above questions answered.

Record review of the Complaint Form completed by Patient #1's representative/daughter sent to the DSHS dated 01/06/15 revealed "no one from the hospital has responded to my request for an explanation to why the hospital failed to provide my mother with the medical care she needed to stop the myocardial infarction." Enclosed was a copy of the letter dated 11/27/14 sent to the facility's PSO. Patient #1's representative/daughter stated the PSO indicated the "hospital committee would review my allegations. To date, I have heard absolutely nothing from [the facility]. Why?"

Record review of Patient #1's facility electronic records, Emergency Provider Report, revealed she was a 71 year old female, presented to the Emergency Department (ED) on 02/01/14 via Emergency Medical Services (EMS) following a fall at home. Upon arrival to the ED at 1049, Patient #1 was in respiratory distress; required endotracheal intubation at 1143 due to respiratory and metabolic acidosis by Arterial Blood Gas (ABG). Electrocardiogram (ECG) completed at 1052 indicated tachycardia (abnormal high heart rate); with normal ST waves and no evidence of ST elevation. Initial Troponin at 1052 was 0.15 and repeated Troponin at 1136 was 0.09 (normal ranges are 0.00-0.04). The radiographic examination indicated diffuse interstitial pulmonary edema. The patient was treated with Nitroglycerin infusion, Morphine, and Lasix. Cardiopulmonary resuscitation (CPR) was initiated at 1212 due to ventricular tachycardia and was discontinued at 1226 due to Patient #1 continued in asystole (flatline) despite CPR efforts; and no femoral pulse found. Patient #1's time of death was called at 1226. Disposition included Primary Impression of Cardiopulmonary Arrest. Secondary impressions included elevated Troponin, Hyperglycemia, Pulmonary Edema, and Respiratory Failure.

Record review of the facility's Grievance Log revealed the following Log for Patient #1; "2014-18428", Patient #1's representative/daughter called and stated that her mother died in the ED on 02/01/14; with unmet expectations regarding her care and treatment. The log indicated she would submit a letter to provide details. Further review of the Log revealed the status documented, "Resolved" and the Date Resolved was "11/14/14." Review of the written allegations/complaint letter sent to PSO #1 dated 11/27/14 revealed a postmarked envelope dated 12/01/14; and was mailed directly to PSO #1 to the facility's Hospital A. The facility was unable to provide evidence that another Grievance Log was initiated after receipt of Patient #1's daughter's letter dated 11/27/14; or that the Grievance, 2014-18428 was re-opened.

Record review of the facility's investigation, "Incident #200361", undated, and not signed revealed a review of Patient #1's medical records in detail titled, "Summary of Events". Incident #200361 included 11 Allegations with a detailed Analysis, and Related Systems/Processes. Incident #200361 concluded with Systems Improvements and/or Follow-Up Actions; based on the analysis of the allegations; and concluded with the Measurements/Sustainability of Compliance Related to Standards.

During an interview on 04/30/15 at 11:50 AM with the PSO#1, during the time of this complaint, revealed she was contacted by telephone in October 2014 by Patient #1's representative/daughter regarding multiple complaints/allegations regarding her Mother's care she received on 02/01/14. PSO #1 indicated she asked Patient #1's representative/daughter if she could send a letter regarding her complaints/allegations. PSO #1 stated she began an investigation; but left the PSO position in December. PSO #1 stated there had already been a previous completed investigation, "Incident #200361" that was completed and sent to The Joint Commission (TJC) regarding the allegations/complaint alleged by Patient #1's representative/daughter; however PSO #1 confirmed those investigation findings were not sent to Patient #1's representative/daughter. PSO #1 indicated she sent a letter to Patient #1's representative/daughter dated 10/22/14 following their phone conversation which indicated; her concerns were being addressed through the Quality Review Process. PSO #1 stated that the policy included an initial response to the complainant within 7 days; which was her letter dated 10/22/14 and, once the investigation was completed; a response was supposed to be sent to the complainant. PSO #1 indicated the facility had "dropped the ball" regarding a written response to Patient #1's representative/daughter grievance dated 11/27/14 because of the transition in PSO's.

During an interview on 05/04/15 at 10:35 AM with the Director of Clinical Outcomes (DCO) revealed she had previously received Patient #1's representative/daughter's complaints directly from TJC on 04/16/14. The DCO stated an investigation was completed, ("Incident #200361," undated) and this detailed investigation response that included 11 Allegations with a detailed Analysis and Related Systems/Processes was sent to TJC on 06/11/14. The DCO stated the facility received the complaints/grievance letter dated 11/27/14 from Patient #1's daughter on 02/19/15; despite a letter postmarked date of 12/01/14. The DCO confirmed a written response had not been sent to Patient #1's daughter regarding her allegations/complaints that included; steps taken on behalf of Patient #1 to investigate the written grievance, the results of the grievance process, and the date of completion in accordance with the facility's policy. The DCO stated it would be hard to respond to Patient #1's daughter letter because the facility would have to, "either defend each statement [allegation]", and/or appear "antagonistic," and the daughter was grieving. The DCO stated she sent a letter to Patient #1's representative/daughter dated 02/23/15 indicating her allegations/complaints had already been investigated. The DCO confirmed the facility's process and procedures for response to Grievances included a response to include; the steps taken to investigate, and the results of the investigation; however, there were concerns of possible legal action, and she did not want to give Patient #1's daughter "ammunition in writing." The DCO confirmed the facility's Grievance policy included a written response to the complainant that provided adequate information to address each item/allegation.

Record review of the letter dated 02/23/15 completed by the DCO and sent to Patient #1's representative/daughter revealed that her concerns were addressed through the facility's Quality Review Process in May 2014. The letter stated this was "a confidential process to evaluate the quality and appropriateness" of Patient #1's visit at the facility. The letter stated the concerns had been investigated and addressed with the hospital and medical staff members involved, and a response to Patient #1's daughter's concerns had been accepted by The Joint Commission. The letter did not include the results of the investigation to include adequate information to address each of the 7 allegations alleged by Patient #1's representative/daughter.