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.

SIERRA MEDICAL CENTER 1625 MEDICAL CENTER DR EL PASO, TX 79902 Oct. 30, 2012
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility policies, documentation, and interview, it was determined that the facility failed to ensure the grievance process was followed regarding time frames for response to a complaint.

Findings were:

Facility Based Policy entitled, " Grievance and Complaint Resolution " stated in part,
" A. "Patient Grievance" is a formal or informal written or verbal complaint (when a verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient ' s representative, regarding the patient ' s care, abuse or neglect, patient harm, ...
V. Procedure
D. A response to the grievance will be provided within seven (7 ) business days. If the
grievance will not be resolved , or the investigation not completed within 7 business
days, the director/designee will inform the patient that the hospital is still working on it
and will follow up with a written response within a stated number of days, not to
exceed thirty (30) days ..."

Risk Management had documentation of several phone calls from the family of patient #1. On 07/10/12, in a phone call, the family expressed concerns over poor service.
The family of Patient #1 sent a letter to the facility 09/14/12 that stated in part, " ...From our understanding some internal action and peer review rating was given, which we were told is confidential information. Besides that, we do not understand what the final outcome of the review was, except that we could contact you ...My sister was released in a semi conscious state from your ER after having a Cat of her brain which we were told was normal. We want to know why 3 days later she was in a coma with no gag reflex due to a [DIAGNOSES REDACTED] the size of fist. We want to know what the final decision about her medical treatment was, what is to be done about what happened. "
In a review of facility available documentation there was no written response provided related to the family's complaint/grievance within the time frame specified by facility based policy.
In an interview, Staff member #1 confirmed there was no written response to the complaint/grievance within the specified time frame.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility policies, documentation, and interview, it was determined that the facility failed to ensure that with resolution of a grievance the patient and/or representative was provided a 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.

Findings were:

Facility Based Policy entitled, " Grievance and Complaint Resolution " stated in part,
" A. "Patient Grievance" is a formal or informal written or verbal complaint (when a verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient ' s representative, regarding the patient ' s care, abuse or neglect, patient harm, ...
V. Procedure...
I. Written notice of the hospital ' s determination regarding the grievance will be
communicated to the patient or patient representative in a understandable language
and manner. The notice will contain:
1. The date of receipt of grievance;
2. The name of the hospital contact person and phone number;
3. The steps taken on behalf of the patient to investigate the grievance and date completed
4. The results of the grievance process and;
5. The date of completion.
J. The hospital ' s response will include adequate information to address each and
every item stated in the grievance. The response is not intended to be an exhaustive
explanation of every action. "

Risk Management had documentation of several phone calls from the family of patient #1. On 07/10/12, in a phone call, the family expressed concerns over poor service.
The family of Patient #1 sent a letter to the facility 09/14/12 that stated in part, " ...From our understanding some internal action and peer review rating was given, which we were told is confidential information. Besides that, we do not understand what the final outcome of the review was, except that we could contact you ...My sister was released in a semi conscious state from your ER after having a Cat of her brain which we were told was normal. We want to know why 3 days later she was in a coma with no gag reflex due to a [DIAGNOSES REDACTED] the size of fist. We want to know what the final decision about her medical treatment was, what is to be done about what happened. "
In a review of available documentation there was no written notice of the facility's grievance resolution 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 provided to the complainant. The letter from Patient #1's family specifically requested follow up regarding the results of the investigation.
In an interview, Staff member #1 confirmed there was no written notice of the facility's grievance resolution 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 provided to the complainant.