The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

METHODIST DALLAS MEDICAL CENTER 1441 NORTH BECKLEY AVENUE DALLAS, TX 75203 July 14, 2014
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, 1 of 1 patient (Patient #1) was not provided a written notice of its decision after the facility's internal investigation was completed. Patient #1 was the subject of a complaint received by the Department on 5/6/14.

Findings included:

The complaint log reflected a grievance process was initiated on 3/24/14 on Patient #1. An initial letter was sent to the complainant on 3/28/14. The letter indicated the complainant would be informed after an internal investigation was completed.

In an interview on 5/28/14 at 11:10 AM, Personnel #2 confirmed that a follow-up letter was not provided to the complainant.

Policy # RI 004 "Complaint Grievance..." effective 3/31/14 pages 2 and 3 required "7. Grievances should be responded in writing...9. If a review and reply cannot be completed within 7 calendar days of the receipt...acknowledgment of receipt of the grievance and a reasonable time frame to respond to the issues should be communicated to the...complainant...10. Grievance responses should be completed...generally within 30 calendar days of receipt...If the final response cannot be completed within 30 days, attempts should be made to notify the...complainant of the status of the investigation and response."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview, a registered nurse (RN) did not supervise and evaluate the nursing care for 1 of 1 patient (Patient #1) who was the subject of a complaint received by the Department on 5/6/14. The RN did not follow a physician's order written on 3/18/14.

Findings included:

Patient #1 had a surgical procedure: total right shoulder replacement on 3/18/14. Patient #1 was subsequently admitted as planned. A physician's order included "Nursing...Incentive spirometer every hour while awake." There was no documentation indicating the incentive spirometry treatment was performed.

In an interview at 5/29/14 at approximately 10:00 AM, Personnel #5 (Director of Medical/Surgical Nursing) confirmed there was no record that the nursing staff performed this nursing task as ordered by the physician.

Policy PC 050: "Patient Assessment and Reassessment" effective 3/30/12 required "PURPOSE: to ensure that each patient's physical, psychological...is assessed to determine the patient care needs..."