HospitalInspections.org

Based on interview and record review, the facility failed to adhere to its grievance policy for 1 of 2 sampled patients with grievances (Patient # 11). The facility failed to ensure:

? A grievance filed by Patient ID # 11 was fully investigated in a timely manner.

? Patient ID # 11 was provided written follow-up regarding the progress of the investigation.

Findings include:

TX 00194765

Record review on 05-20-14 of facility form titled "Patient Issue," dated 11-18-13 revealed concerns expressed by Patient ID # 11 regarding billing and quality of care issues. Quality of care issues expressed by Patient ID # 11 documented on this form included the following:

? Patient was told she would receive a course of treatment and a team of doctors, including a pain management doctor. She alleged she received neither.

? Patient alleged her medications were "cut off cold turkey;" and she had a convulsion as a result of this.

? Alleged her room was 'filthy" and there was no light in the bathroom.

? Stated she experienced "Morphine withdrawal;" she was given Motrin every 12 hours, which was not effective for her pain.

Record review on 05-20-14 of facility form titled "Corrective Action Form," dated
02-05-14, completed by Guest Relations staff ID # 15 revealed a synopsis of the patient's concerns of 11-18-13; there was a section for investigation findings. This form was forwarded to the Unit Director ID # 8 with a notation: "please return this completed form to guest relations on or before 02-17-14."

Further review of this same form revealed an investigation was documented and signed by Unit Director ID # 8, dated 02-26-14.

Continued review of facility's investigation revealed a letter to Patient ID # 11 that addressed the facility investigation of the quality of care concerns. The letter was dated 03-05-2014; two (2) and ? months after the grievance was filed.

Interview on 05-26-14 at 2: 40 p.m. with the Manager of Guest Relations ID # 4, she stated there were 16 liaisons assigned to various units. Once a complaint was received, it was triaged to one of three senior Patient Liaisons; and then routed to the proper department director for investigation.

Interview on 05-26-14 at 2:15 p.m. with Senior Patient Liaison # 15, she said she was the staff person who completed the "Patient Issue" form dated 11-20-13 for Patient ID # 11. She stated the concerns were first routed to patient accounting, as it involved a billing issue.

Interview on 05-26-14 at 2:30 p.m. with Director of Business Practices / ID # 2 she stated the process for a billing issue concern was: Patient Accounting would investigate to determine if there was an accounting error or if insurance payment was pending. If neither issue was present, a financial counselor would contact the patient to offer assistance, including a possible discount. Director of Business Practices/ ID # 2 went on to say that conversations were conducted with Patient # 11 regarding billing, but facility was unable to locate documentation of this.

Business Practices Director ID # 2 stated there should not have been a two (2) month gap in investigating the quality of care concerns expressed by Patient # 11. She reported that if a complaint contained both quality of care concerns and billing issues, these issues should be investigated simultaneously. Business Practices Director/ ID # 2 could not explain the delay but stated it appeared that the billing issue was initially routed to Accounting in November 2013 and not forwarded to nursing department director for investigation until February 2014.

Record review on 05-27-14 of the facility's Policy and Procedure for Patients and Legally Authorized Representative (LAR) Grievance, revised/reviewed on 4/30/14, revealed the following:

"II. DEFINITIONS...

Grievance:
If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present...then the complaint is considered a grievance.
A written complaint is always considered a grievance whether from an inpatient, outpatient, released/discharged patient or his/her LAR/companion regarding care provided...or the hospital's compliance with the Conditions of Participation...
D. Each department/unit director is accountable for investigating and assisting with resolving patient grievances related to their areas....findings from the conclusions will be reported to the patient advocate/liaison who is responsible for developing the response to the patient.
E. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital will inform the patient or patient's LAR that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within 21 days.....
F. The response must be communicated in a language and manner that the patient/patient's LAR/companion understands and will include:
1. the name of a hospital contact
2. the steps taken on behalf of the patient to investigate the grievance,
3. a summary of the results of the grievance process and
4. the date of completion.
G....Documentation of actions taken and all correspondence will be maintained...."

Based on record review and interview, the facility failed to provide 1 of 2 patients (#1) with a grievance a written notice of its decision with steps taken on behalf of the patient, the results of the grievance process and the date of completion.

Complaint #TX00194372

Findings include:

Patient #1

Record review of Patient #1's facility electronic records revealed she was admitted to the Main 4th floor Southwest unit on 10/30/13 after having lumber laminectomy surgery. She was discharged on 11/7/13.

Record review of the facility's Grievance Log revealed Patient #1 filed a grievance by letter received on 12/4/13.

Record review of the facility's investigation dated 12/4/13 into the complaint revealed the letter from Patient #1 received by the facility. Patient #1 made the following notation: "The following morning (11/2/13) I requested (Senior Patient Liaison #12), the patient liaison come to visit, I asked for the nurse manager and (Nurse Manager #16) and (Senior Patient Liaison #12) came on Nov. 6.and promised to investigate the allegations and contact me.No contact yet." The patient's complaints in the letter were about infiltrated IV's and the time it took to get a new IV started without receiving anything for pain. Her pain control was by a pain pump that put medication into her IV. Her indwelling catheter was removed, but she was not assessed for ability to void until her bladder was extremely full and the staff refused to straight catheterize her.

Further review of the investigation revealed a letter written by Senior Patient Liaison #12 to Patient #1 dated 12/20/13 which stated, "We take all comments from patients very seriously, and have reviewed your concerns with all staff involved. Although it is not pleasant to receive negative feedback, we will take this opportunity to review our processes and procedures. We hope to continue to provide you with your healthcare needs." There was no information about any decisions, steps taken or the results of the investigation. There was no signature on the form.

Interview on 5/20/14 at 2:00 p.m. with Senior Patient Liaison #12, she said she and Nursing Manager #16 went to see Patient #1 and listened to her complaints. She said she felt they had resolved her issues by the time she was discharged, so they did not write up a grievance form.

Interview on 5/20/14 at 2:25 p.m. with Manager of Guest Relations # 4 and Senior Patient Liaison #12, they said the letter to Patient #1 had been mailed to her. Senior Patient Liaison #12 said she signed a copy of the letter and gave it to her secretary to mail. A copy of the letter was scanned into the electronic record. Manager of Guest Relations # 4 brought up the letter on her computer screen and agreed the letter had not been signed. She said it was not the facility's routine to send the letters registered or certified and they did not keep a log of when the letters were mailed. She agreed at this time there was no way that the facility could show the letter was mailed to the patient.

Interview on 5/20/14 at 2:45 p.m. with Director of Business Practices # 2, she said the facility's process for sending response letters was that the letter would be signed by the responsible liaison who would give it to the secretary to mail. The signed letter would be entered into the electronic record to show it had been mailed. She said the letter would have to be signed to show it had been mailed.

Record review of the facility's Policy and Procedure for Patients and Legally Authorized Representative (LAR) Grievance dated 1/1981 and revised/reviewed on 4/30/14 revealed the following:
"II. DEFINITIONS...
Grievance:...
If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present...then the complaint is considered a grievance.
A written complaint is always considered a grievance whether from an inpatient, outpatient, released/discharged patient or his/her LAR/companion regarding care provided...or the hospital's compliance with the Conditions of Participation...
D. Each department/unit director is accountable for investigating and assisting with resolving patient grievances related to their areas....findings from the conclusions will be reported to the patient advocate/liaison who is responsible for developing the response to the patient.
E. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital will inform the patient or patient's LAR that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within 21 days.....
F. The response must be communicated in a language and manner that the patient/patient's LAR/companion understands and will include:
1. the name of a hospital contact
2. the steps taken on behalf of the patient to investigate the grievance,
3. a summary of the results of the grievance process and
4. the date of completion.
G....Documentation of actions taken and all correspondence will be maintained...."