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.


Based on a review of facility documentation and staff interview, the facility failed to provide written notice of its decision, steps of the investigation and investigation results in the case of 1 of 1 patient charts reviewed wherein the patient or patient's representative made a grievance.

Findings were:

A review of the clinical record of Patient #3 revealed Patient/Family Grievance Forms filed by the [AGE]-year-old patient's mother included the following:
o 3/24/15 at 9:03 a.m.: "[Patient #3] asked for a formal complaint form and was told there were none. Staff didn't attempt to get her one until I called. This is a violation of her rights!"
o 3/27/15 at 7:36 a.m.: "[Patient #3] was left alone and unsupervised on the unit while everyone was at the gym. Completely unsafe!"
o 3/28/15 at 9:45 a.m.: "My takes a medication for when she is on her period ONLY. Staff have been giving her the meds everyday. She called me to tell me she is almost out of this med even though on Tues I dropped of half full bottle."
o 3/28/15 at 2:58 p.m.: "I asked at intake/admission if I needed to withdraw [Patient #3] and was told no. UBH would handle it. I received a call from her school on Thursday (she was admitted on Monday) that I need to withdraw her because she was accumulating absences and was at UBH. I called EPISD and they said UBH should have known that because they just talked to everyone a week earlier..."

These complaints had no Result/Disposition of Grievance filled in on the form. In addition, the patient or patient's representative had not been informed of the corrective actions taken by the facility to address these issues, nor was there a resolution noted. There was a note on the 3/27/15 complaint regarding Patient #3 being left alone on the unit which stated, "Spoke [with] mom...on phone. Reviewed cameras. Unfounded. Staff present. Mom happy to be notified..."

In an interview with the Performance Improvement/Risk Management Director, on the morning of 6/3/15 in the facility meeting room, she stated, "There were so many complaints we received from this patient's mother. We tried to address each of them as they came up. There were some issues though with the grievance process around this time." She stated the facility's patient advocate had been "out" for the entire month of March, 2015, and also April 2-4, 2015. She did admit, "There may have been some things that got missed during that time though...We had some holes in our grievance process. I think one of the managers just didn't know what they were supposed to do. We now have a new patient advocate and we've addressed it. I know we didn't really send anything out regarding [the mother of Patient #3's] March complaints... "

Facility policy entitled Patient and Family Grievance/The Role of the Patient Advocate, date issued 8/2013, stated in part:
"4.7 The patient shall be given a copy of the complaint and final decision and a copy shall be filed in the patient's record...6.0 The grievance and problem resolution/follow up should be documented. This documentation should include...pertinent investigational information, resolution of grievance/follow up, signature of Patient Advocate...9.0 On occasions in which family members/parents believe their rights have not been respected or provided for, they should be asked to address the issue with the Chief Nursing Officer, nursing supervisor, Program Director or attending physician. If the issue is not satisfactorily resolved at that level, the above procedures should be followed... "

These findings were again confirmed in an interview with the facility Chief Executive Officer and other administrative on the afternoon of 6/3/15 in the facility meeting room.