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BAYLOR MEDICAL CENTER AT IRVING 1901 N MACARTHUR BLVD IRVING, TX 75061 May 9, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on resort review and interview via email, the hospital failed to ensure in its resolution of the grievance concerning the quality of care, the patient/family received written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion, in that, the hospital did not complete and provide a resolution letter to Patient #4's family for the complaint/grievance received by the hospital on [DATE].

Findings included

The 4/20/17 Complaint report reflected multiple issues on multiple days and included, "4/19 14:15 (4/19/17 4:15 PM) Personnel #5 came into my office and stated that (the daughter) had informed her that the PCT was unnecessarily rough with her father...yesterday...were repositioning the patient in bed that they slammed his head against the rail...Personnel #5 stated that while they were moving him that he moved his body causing his head to brush the head rail. Personnel #5 states that there was no redness, abrasion or anything to indicate that he had hit his head. The daughter stated how do you know; you weren't in the room. Personnel #5 reminded her that she was in the room, that she was the one who was helping to reposition him. The daughter then stated that PCT body slammed her father into the bed and banged his head on the rail..."

The 5/10/17 11:44 AM return email from Personnel #1 regarding the question of hospital response letters to the complainant in regards to the unnecessary roughness complaint/grievance stated, "I have checked and no letters were sent to the family."

The hospital's 9/01/16 "Patient Complaints and Grievances" policy required, "Grievance...regarding the patient's care, abuse or neglect, or issues related to the facility's compliance with the Centers for Medicare and Medicaid Services Conditions of Participation...When a grievance is resolved, the patient is notified, in writing, of the resolution..."

The hospital's March 2013, last reviewed "Patient Abuse, Neglect, Exploitation and Harassment Reporting" policy required, "...informs the patient of the disposition of the allegation within two (2) days of the completion of the investigation..."
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
Based on record review and interview, the hospital failed to ensure the discharge summary was complete with outcome of hospitalization , disposition of care and provisions for follow-up care, in that, 1 of 10 patients (Patient #4) discharge summary did not include the patient's (Physical/Occupational Therapy) PT/OT Evaluation/ needs/progress.

Findings included

The electronic medical record for Patient #4's admit on 4/18/17 through 4/21/17 reflected, "4/18/17 Progress Note...Pt/OT (Evaluation) eval, SNF (Skilled Nursing Facility) eval per family request...Physician #15...4/19/17 Progress note...Pt/OT eval, SNF eval per family request...Physician #15...4/20/17 Progress note...Pt/OT eval, SNF eval per family request...Physician #15...4/21/17 Discharge Summary...arrangements were made to discharge the patient to skilled nursing facility...Physician #15..."

There was no PT/OT Evaluation or treatment documented for the admission. There was no documentation of PT/OT eval and progress for the admission on the physician discharge summary.

During an interview on 5/09/17 ending at 11:00 AM, Personnel #8 was asked to confirm that each day's physician progress notes reflected OT/PT Eval. Personnel #8 confirmed and stated, "Yes." Personnel #8 was asked for the physician order for PT/OT eval and treat. Personnel #8 stated, "There is not one." Personnel #8 was informed that Patient #4's discharge summary did not include the patient's PT/OT Evaluation/needs/progress. Personnel #8 confirmed the finding and stated, "Correct."

During an interview on 5/09/17 ending at 11:46 PM, Personnel #13 was asked if physicians put their own orders into the electronic medical record. Personnel #13 stated, "Yes. They do." Personnel #13 was asked what would happen if the hospital had found the issue with the physician documentation of the PT/OT Eval on the progress notes without the physician ordering the PT/OT Eval. Personnel #13 stated, "We would take it through PEER Review."