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TEXAS HEALTH HUGULEY HOSPITAL FORT WORTH SOUTH 11801 SOUTH FREEWAY BURLESON, TX 76028 Aug. 31, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, the hospital did not provide a timely written notice of its decision to 2 of 10 patients (Patient #1 and Patient #9) who lodged complaints on 5/12/15 and 3/11/15 respectively.

Findings included:

- Patient #1 presented in the hospital's emergency department (ED) on 5/12/15 for "lower back, pelvic pain with radiation down right leg x1 day." At 11:00 AM, Personnel # 7 noted "assisted patient getting dressed...Wanted names of all who cared for her, stating she was not happy with the care." At 11:15 AM, a physician re-evaluated the patient and noted the patient was "upset...she did not want to talk to me anymore." At 12:00 PM, Personnel #7 noted that Personnel #2 saw the patient prior to discharge. There was no evidence provided to the surveyor that Patient #1's complaint was resolved. No letter of response to the complaint was sent to Patient #1.

The hospital's complaint log for ED complaints from 3/1/15 through 8/31/15 did not show that Patient #1 complained to a physician and nurse on 5/12/15.

In an interview on 8/31/15 at 10:00 AM, Personnel #2 was asked if he entered Patient #1's complaint in the complaint log book. He replied "no." Personnel #2 was asked what Patient #1's complaint was. He replied that he could not remember. He stated "I believe Patient #1's complaint was resolved." Personnel #2 was asked to provide evidence that Patient #1's complaint was resolved. None was provided to the surveyor.

- The hospital received a complaint from Patient #9 on 3/11/15. A written response was provided to the patient on 5/19/15, 70 days after the complaint was received. There was no evidence provided to the surveyor for any communication with Patient #9, verbal or written between 3/11/15 through 5/18/15. The hospital did not adhere to their policy.

In an interview on 8/31/15 at approximately 12:50 PM, Personnel #5 confirmed the written response provided to Patient #9 was not within the time frame specified in the hospital policy.

Policy #R "Patient Complaints..." revised 2/2015 page 3 required "Every effort will be made to contact and resolve complaints...either by phone or meeting as appropriate. If the grievance cannot be resolved...the resolution process may be completed by correspondence within 7 days...if not resolved...the hospital will inform the patient that the hospital is still working to resolve the grievance...the hospital will follow-up with a written correspondence within 30 days..."