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.

LONE STAR BEHAVIORAL HEALTH CYPRESS 16303 GRANT ROAD CYPRESS, TX Jan. 8, 2014
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, the facility failed to thoroughly investigate a grievance to resolution and provide a written notice of the resolution of the grievance for 1 of 5 patients (PT #1) reviewed for being kept in the facility involuntarily.

Findings include:

Pt. #1
Record review of a type written letter from Pt. #1 dated 10/4/13 revealed she entered the facility voluntarily on 10/2/13 from a Hospital in College Station. She stated that on 10/5/13 she was stable and felt much better. She wanted to leave and filled out a request to be discharged around noon. She was told by the physician that it was the policy of the facility not to discharge anyone over the weekend unless they left AMA (Against Medical Advice). The resident left AMA on 10/7/13 at 5:50 p.m. This letter was "Cc" to the State Agency and to the facility.

Record review of Pt. #1's Request for Release From Voluntary admitted d 10/4/13 at 6:52 p.m. revealed the following information on the sheet:
"I understand that twenty-four (24) hours from the time this letter has been signed and dated, I must be released from my voluntary admission unless:
1. the request has been withdrawn ...
2. An application for involuntary hospitalization is filed and an Order for Protective custody has been secured ..."
Under Nursing Responsibilities revealed the following:
"I have explained that the attending physician or designee had determined the (sic) he/she will be:...
3. Detained here against his/her will for up to 24 hours and that the physician or his designee has determined that a court order will be sought to hold him/her against his/her will." (This choice was circled. This was signed by RN #14 on 10/4/13 at 6:10 p.m.
The "Letter of Retraction of Request to Be Released" on the same sheet was blank.

Record review of Pt. #1's closed record revealed there were no progress notes or physician statement from Friday - 10/4, Saturday - 10/5, or Sunday - 10/6/13 showing Pt. #1 had been assessed by a physician. There was no application for involuntary hospitalization or any documented call for a warrent to detain the resident.

Further review of Pt. #1's record revealed a discharge Against Medical Advice signed and dated by the patient on 10/7/13 at 5:40 p.m.

Interview on 1/8/14 at 11:00 a.m. with Compliance Officer/Risk Manager #2, she was asked if she had received the letter from Pt. #1. She said she had. She was asked what she did about the letter. She said she tried to call Pt. #1 twice, but did not get a response. She said she reviewed the patient's record and saw there had not been a Letter of Retraction of Request to Be Released. (She did not mention that the resident had not been seen or assessed by a physician from 10/4 to 10/6/13.) She said she had not responded by letter. She said she thought that since it was sent to the State Agency, she did not have to address the concerns. She said she was not sure what she was supposed to do. She did not have anything in writing.

Record review of the facility's Complaint/Grievance Policy dated 10/11 and revised on 8/12 revealed the following:
"IV. POLICY:...
1. Complaints or grievances may be in written or verbal form and received within 30 days of occurrence...
3. The Hospital Quality Management ensures the patient is provided written notice of its decision regarding a complaint/grievance within 7 days of the Hospital's receipt of the grievance. the written notice shall contain the following:
a. Name of the Hospital contact person.
b. Steps taken on behalf of the patient to investigate the grievance.
c. Results of the grievance process.
d. Date of completion....
A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with CoPs. For the purposes of this requirement an Email or fax is considered 'written'..."