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Based on interview and record review, the facility failed to provide a Patient with a written notice of decision that contained the steps taken on behalf of the Patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 1 Patient's reviewed (Patient #1) with an allegation of abuse reported on 2/25/18; resulting in a formal grievance. Specifically,

As of 03/21/18, Patient #1 had not received a written response from the facility with adequate information to include: steps taken on behalf of Patient #1 to investigate the 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 communicate the outcomes to Patient #1 regarding the allegations of abuse expressed by Patient #1 regarding his rights, treatment, and satisfaction.

Findings included:

Complaint # TX 00282068.

Review of the complaint intake report for TX00282068 revealed Patient #1 made an allegation of abuse when he stated that Mental Health Tech (MHT) - A grabbed him by the throat and kneed him in the stomach. Patient #1 indicated they began to scuffle and ended up at the door. MHT A then used a "walkie talkie" and other staff (Registered Nurse-A) went in to his bedroom and he was injected. Patient #1 stated he attempted to contact 911 and was placed on phone restrictions. Patient #1 indicated he spoke with the Patient Advocate (PA) and she informed him the police do not have jurisdiction at the facility.

Review of the facility's Patient Complaint and Grievance Process Policy effective 6/2016 revealed the following, in part:
A patient grievance is a formal, written or verbal complaint which is filed by a patient, when a patient issue cannot be resolved promptly. A written response will be provided to the patient within (7) seven working days of the initial meeting of the Advocate and the patient. The response will include:
a. The name of the hospital contact person.
b. The results of the grievance process.
c. The date of completion.

Record review of the facility's Grievances and Complaints revealed on 2/27/18 the previous Patient Advocate B and Director of Quality received a complaint by Patient #1 alleging an allegation of physical abuse against MHT A; that grabbed his throat and kneed him in the stomach following a verbal confrontation. Further review revealed Patient #1 indicated he wanted to call this allegation in to the state, as well as a "full investigation with written response sent to his address because he is leaving tomorrow but wants to make sure this is investigated and response given to him."

Review of the facility's documentation and evidence provided regarding this specific allegation/grievance filed by Patient #1 revealed as of 3/21/18 he was not provided with a written notice of decision that contained the steps taken on behalf of the Patient to investigate the grievance, the results of the grievance process, and the date of completion in accordance with the facility's Complaint and Grievance Process Policy.


During an interview on 3/21/18 at 06:45 PM with the previous Patient Advocate (PA) B stated she met with Patient #1 regarding to the allegations of abuse lodged against MHT A. The PA B confirmed a written response had not been sent to Patient #1 regarding his allegations/complaints that included; steps taken on behalf of Patient #1 to investigate the grievance, the results of the grievance process, and the date of completion in accordance with the facility's policy because she had not been directed to by the Chief Executive Officer (CEO). The PA B confirmed the facility's process and procedures for response to Grievances included a response to the Patient which included; the steps taken to investigate, and the results of the investigation. The PA B confirmed the facility's Grievance policy included a written response to the complainant that provided adequate information to address the complaints. The PA B indicated she was not certain if this specific allegation of abuse was determined to be a "complaint or a grievance" and therefore had emailed the CEO for clarification and direction.

Code of Federal Regulations (CFR) §482.13(a)(2): A-0118 Interpretive guidelines define Patient Grievance as follows:
A "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489.

Based on review of records and interviews, the facility failed to ensure that patients were able to exercise their rights for 1 of 1 patient (Patient #1) reviewed for rights violations. Specifically,

On 2/25/18, Patient #1 made an allegation of physical abuse against a facility staff and attempted to call 911 to report the allegation of abuse to the local police department. Patient #1 was then placed on phone restrictions after calling 911 to report his allegation of abuse against the staff member; without clinical justification and before a thorough investigation had been completed to determine the validity of the allegation made.

This deficient practice affected Patient #1's rights to report an allegation of physical abuse/assault against facility staff to the local Police Department for consideration of unlawful evaluation.

Findings included:

Complaint TX00282068.

Review of the Patient's Bill of Rights given to patients (undated) revealed the following in part, Patients 5. Have the right to be free from mistreatment, abuse, neglect, and exploitation. 9. Have the right to talk and write to people outside the hospital. Have the right to have visitors in private, make private phone calls, .... In no case may your right to contact or be contacted by an attorney, the department, the courts, or the state attorney general be limited.

Review of the complaint intake report for TX00282068 revealed Patient #1 made an allegation of physical abuse against a facility Mental Health Tech (MHT) A; alleging he grabbed him by the throat and kneed him in the stomach. Patient #1 stated they began to scuffle and ended up at the door. Patient #1 stated he "attempted to contact 911, and was placed on phone restrictions." Patient #1 indicated he spoke to the facility's Patient Advocate (PA) B and she informed him the "police do not have jurisdiction at the facility." Patient #1 stated his left knee was injured and he had pain to his stomach area.

Review of the facility's Grievances and Complaints revealed on 2/27/18 the previous Patient Advocate B and Director of Quality received a complaint by Patient #1 alleging an allegation of physical abuse against MHT A; that grabbed his throat and kneed him in the stomach. Further review revealed Patient #1 indicated he wanted to call this allegation in to the state, as well as a "full investigation with written response sent to his address because he is leaving tomorrow but wants to make sure this is investigated and response given to him."

Upon review of the surveillance video on 3/21/18 revealed on 2/25/18 at 06:06 AM MHT A entered into Patient #1's bedroom. From 06:06AM to 06:08AM, MHT A was in Patient #1's bedroom. At 06:08 AM MHT A is seen to return to the doorway of Patient #1's bedroom and used a radio ["walkie talkie" to call for assistance]. The allegation made by Patient #1 occurred during this time frame when MHT A was in Patient #1's bedroom where video surveillance could not support or deny the allegation occurred; and additionally, there were no other witnesses.

Review of Nursing Progress note dated 2/25/18 at 13:54 documented; Patient (Pt.) observed to be on phone with 911, verbalizing that he was assaulted by staff. Pt voiced that he was in his room and was physically attacked by staff. Phone call ended. Pt. placed on unit restrictions for 24 hours. Physician A aware. Approximately 5 minutes later, 2 police officers present to facility. Apologized and explained to police officers.

Review of the physician orders (PO) dated 2/25/18 at 13:39 revealed the following: "No phone privileges. Pt calling 911 - giving false info." There was no further details to include clinical justification, or time limitations.

Review of the facility policy titled Restriction of Rights effective 06/2016 indicated that restriction of rights required documentation for the clinical reasons for the restriction and the duration of the restriction in the patient's clinical record. Restriction of Rights requires a Doctor's order. A. The order must delineate the "clinical justification for the Restriction of rights." B. The order must specify which right(s) are to be denied. C. The order must be "time-limited" with the time limitation stated in the order. Restriction of rights is documented in the patient medical record, including patient response and actions. Further review revealed rights restriction may not include restriction to communicate with legal counsel, the department, the courts, or the state attorney general.

During an interview on 3/21/18 at 9:50 AM with Mental Health Tech B stated if a patient had an allegation of abuse they could call the 1-800 number to Adult Protective Services (APS) to report. When this surveyor asked if a Patient could call 911 and report an allegation of abuse against staff; she indicated that Patients "can't call 911 from the hospital." MHT B stated that when patients use the phone to call 911 that the police department will call back and talk to the facility staff in the front where they explain to the police department that the patients are hospitalized for psychiatric conditions.

During an interview on 3/21/18 at 10:00 AM with Registered Nurse (RN) B stated that patients have called 911 before from the facility and then they "have to deny the patient phone privileges."

During an interview on 3/21/18 at 10:25 AM with RN C stated that patients "can call 911 to report allegations of staff abuse." RN C further indicated if patients are calling 911 to report they are being held against their will and they are at the facility on an emergency detention; then it is clinically justified to deny/restrict phone privileges in order to avoid abuse of 911.

During an interview on 3/21/18 at 06:45 PM with the previous Patient Advocate (PA) B confirmed that she was not aware that patients could make an allegation of abuse/assault to the local Police Department for consideration of unlawful evaluation.