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.

CHRISTUS MOTHER FRANCES HOSPITAL 800 EAST DAWSON TYLER, TX 75701 Aug. 20, 2013
VIOLATION: PATIENT RIGHTS: GRIEVANCE PROCEDURES Tag No: A0121
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure patients received clear instructions on the grievance process in 2 of 2 patients (#s' 11 and 15).
This deficient practice had the potential to cause harm in all patients.
Findings include:
Review of an undated admission "Patient Rights and Responsibilities" form revealed the patient had "The right to receive at the time of admission, information about the hospital' s patient rights policies, mechanism for the initiation, review and, when possible, resolution of your patient complaints concerning the quality of care."
During interviews on 08/20/2013 the following was reported:
At 4:15 p.m., Patient #15 reported having her admission information, but not knowing about the complaint and grievance process being explained.
At 4:20 p.m., Patient #11 reported she had completed admission papers. She needed to report a complaint/grievance about her care, but did not know how to report it. The process had not been explained to her.
Review of record revealed she was admitted [DATE], but no signed patient right consents could be found.
During an interview on 08/20/2013 at 5:24 p.m., Staff #12 confirmed the problems with the unsigned consent form.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure complaints and grievances were investigated and resolved in a timely manner in 7 of 18 patients (#s' 1, 3, 8, 9, 10, 12 and 16).
This deficient practice had the potential to cause harm in all patients.
Findings included:
Review of the policy and procedure "Patient Grievances/Complaint Resolution" dated 08/2011 revealed the following:
"Complaint -Those expressions of dissatisfaction that can be addressed by staff at the point of service and do not require a written response.
Grievance - A formal or informal written or verbal complaint that is made to the hospital/clinic by a patient or the patient' s representatives regarding care, abuse or neglect that cannot be promptly addressed at the point of care and requires further review and investigation is considered a grievance.
The formal responses to grievances will be facilitated by the System Office of Patient Advocacy.
All written letters of grievances will be acknowledged in writing. For the subset of grievances related to uncomplicated concerns of care/services, a written response will be provided within 7 days.
For more complex issues that require a formal review, the complainant will be informed that (the hospitals and clinics) will investigate their concerns and respond to them as soon as possible.
In the process of resolving grievances, the hospital will provide the complainant with the following information related to their concerns: the name of the hospital contact person, the steps being taken on behalf of the individual to investigate the complaint, the results of the process and the date of completion of the complaint process."
Review of the complaint/grievance log revealed the following grievances which were not resolved:
*04/30/2013 (received 05/15/2013) Patient #12 reported Staff #13 (ER doctor) came into her room and his mannerism toward her was appalling. "He strolled in and flipped up the breathing mask that was placed over my nose and mouth and said "Lady you're breathing" ... Staff #13 continued his assault on me by stating "there is nothing wrong with you, and you are keeping me away from other patients." Well excuse me, I thought, I felt like a dog, I just wanted to cry right there." According to the grievance log the start date of the review of the complaint was on 07/05/2013 (2 months later). A written acknowledgement was sent to the complainant on 07/05/2013 which revealed the hospital had begun a review of the records and would respond to the complainant with their findings in the next 30 to 45 days. There was no documentation of a resolution as of 08/20/2013.
*06/05/2013 Patient #1 reported a unit tech came into her room in the middle of the night and was rude and very rough with her. The desired outcome was for the supervisors to educate the nurses on their behavior and the correct way to handle patients. There was neither documentation of a written acknowledgment nor resolution of the complaint as of 08/20/2013.
* 07/03/2013 Patient #8 reported Staff #15 ( MD) was rude to his mother. When he called Staff #15(MD) about a reaction he was having to a pneumonia shot, he was told he had other patients to attend to. A written acknowledgement was sent on 07/03/2013, but no resolution had been made as of 08/20/2013.
*07/04/2013 Patient #10 (MDS) dated [DATE] for a blood sugar of 430. Patient #10 reported when he arrived he was put in a chair and put in the waiting room for several hours before he was seen. A written acknowledgement was sent on 07/04/2013 and there was no resolution as of 08/20/2013.
*07/05/2013 Patient #16 reported Staff #13 (ER doctor) was rude and unconcerned about his falls. The desired outcome was for him to treat others better. There was neither documentation of a written acknowledgment nor resolution of the complaint as of 08/20/2013.
*07/15/2013 Patient #9's mother complained about the behavior of the nurse that discharged her son. She stated a security officer came up to her and claimed the nurse's behavior was unprofessional. According to Patient #9's mother, the nurse yanked the IV out of the patient's arm and told him to leave. A written acknowledgement was sent on 07/15/2013 and there was no resolution as of 08/20/2013.
*07/25/2013 Patient #3's family complained about him being discharged after taking a pain pill and the family was not there yet. He was put in the lobby on a bench to wait for his family to pick him up. Also the nurse told him to use his arm after he had a pacemaker put in. The family called to confirm this with the doctor who told them by no means should he use his arm for at least 2 weeks. The discharge instructions did not inform the family about pain management or care after his procedure. The family stated the doctor told them to call and file a grievance. An acknowledgement letter was sent out on 07/25/2013, but there was no resolution.
During an interview on 08/20/2013 at 8:52 a.m., Staff #2 reported when she receives a grievance it is input into the computer and then sent to the appropriate nursing director. They are supposed to send it back with their response. Staff #2 reported she tries to get an acknowledgement letter out to the complainant in 7 days, but that does not always happen. The complaint is closed out in 45 days. The complaints involving staff treatment to patients should have been handled immediately.
At 9:51 a.m. Staff #2 reported she did not have investigations on the complaints. They were having a problem with the computer system reminding the directors of their need to send in the results of their investigation. Staff #2 confirmed the problems found with the grievances. The complaints on the doctors would be discussed on Thursday (08/22/2013) with the physician over the doctors.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure patients received and understood their patient rights in 4 of 18 patients (#s' 1, 8, 11 and 15).
This deficient practice had the potential to cause harm in all patients.
Findings include:
Review of an undated admission "Patient Rights and Responsibilities" form revealed the patient had "The right to receive at the time of admission, information about the hospital's patient rights policies, mechanism for the initiation, review and, when possible, resolution of your patient complaints concerning the quality of care."
During interviews on 08/20/2013 the following was reported:
At 4:15 p.m., Patient #15 reported having her admission information, but not knowing about the complaint and grievance process being explained.
At 4:20 p.m., Patient #11 reported she had completed admission papers. She needed to report a complaint/grievance about her care, but did not know how to report it. The process had not been explained to her.
Review of patient admit records reveal the following:
*Patient #1, admitted [DATE], had a consent form which revealed documentation of verbal consent being given. There was an area on the form to check if the patient received or had been offered a copy of the Patient rights and Responsibilities and this area was not checked.
*Patient #8, admitted [DATE], had a consent form which revealed documentation of consent being given by his wife. There was an area on the form to check if the patient received or had been offered a copy of the Patient rights and Responsibilities and this area was not checked.
* Patient #11, admitted [DATE], did not have signed patient right consents on the chart.
During an interview on 08/20/2013 at 5:24 p.m., Staff #12 confirmed the problems with the consent forms not being checked as received and missing.