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SAN ANTONIO BEHAVIORAL HEALTHCARE HOSPITAL 8550 HUEBNER ROAD SAN ANTONIO, TX Oct. 31, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interview and record review, the facility failed to provide the Patient's Representative with a written notice of decision that contained the steps taken on behalf of the Patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 1 Patient's reviewed (Patient #1) with a grievance lodged by his representative/spouse on 6/21/17. Specifically,

As of 10/25/17, Patient #1's representative/spouse had not received resolution of her grievance, or a written response from the facility with adequate information to include: steps taken on behalf of Patient #1 to investigate the grievance, the results of the grievance process, and the date of completion in accordance with the facility's Grievance policy.

This deficient practice affected Patient #1's rights when the facility failed to communicate the outcomes to Patient #1's representative/spouse regarding the concerns, complaints, and grievance expressed on behalf of Patient #1's rights, treatment, and satisfaction.

Findings included:

Complaint # TX 785.

Review of the facility's Patient Complaint and Grievance Process Policy revised 01/25/17 revealed the following, in part:
A patient grievance is a written or verbal complaint (when the 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, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation or accrediting organization standards.

Procedures included:
L. The patient will be provided with written notice of:
1. The name of the Patient Advocate
2. The steps taken to investigate and resolve the grievance
3. The final result of the complaint and grievance process
4. The date of completion of the complaint and grievance process.


Record review of the facility's Grievances and Complaints revealed on 6/21/17 the facility's Chief Nursing Officer (CNO) received a complaint in person by Patient #1's representative/spouse alleging quality of care issues, and facility neglect regarding his medical diagnosis of hypertension and diabetes. Further review revealed Patient #1's representative/spouse was "very upset, stating her husband could have died here and that he was our responsibility while he was inpatient with us." Further review in the area of problem resolution/follow-up; the Patient Advocate documented that she informed Patient #1's representative/spouse that she would "look into everything that we discussed and get back with her after I had some information for her. She understands that I need to research what happened and is not holding me to a time frame. Letter sent 6/27/17 to [Patient #1's representative/spouse] informing her of the investigation and that food was offered and declined. Once the investigation has concluded she will be notified of the outcome.

Review of the letter dated 6/26/17 to Patient #1's representative/spouse from the facility's Patient Advocate indicated the issues described, including the concerns about the medical treatment Patient #1 received and the admissions process would be reviewed. "Once our investigation is complete, we will inform you of the results."

Further review of the facility's documentation and evidence provided regarding this specific complaint/grievance revealed Patient #1's representative/spouse was not provided with a written notice of decision that contained the steps taken on behalf of the Patient to investigate the grievance, the results of the grievance process, and the date of completion in accordance with the facility's Complaint and Grievance Process Policy.

During an interview on 10/25/17 at 1:55 PM with the Patient Advocate (PA) stated she and the Director of Risk Management/Performance Improvement (DRM/PI) met with Patient #1's representative/spouse regarding her complaints/grievance. The PA confirmed a written response had not been sent to Patient #1's representative/spouse regarding her allegations/complaints that included; steps taken on behalf of Patient #1 to investigate the grievance, the results of the grievance process, and the date of completion in accordance with the facility's policy because Patient #1's representative/spouse stated she did not want a follow-up letter after the investigation. The PA confirmed the facility's process and procedures for response to Grievances included a response to include; the steps taken to investigate, and the results of the investigation; The PA confirmed the facility's Grievance policy included a written response to the complainant that provided adequate information to address the complaints.

During an interview on 10/25/17 at 3:45 PM with Patient #1's representative/spouse stated she had not received any follow up information or a letter from the facility after the investigation was completed. She said she only received the letter dated 6/26/17 as indicated above. She stated that she met with the CNO and the PA initially; and understood her complaints/grievance would be investigated. Patient #1's representative/spouse stated that she did not tell the facility staff that she did not want a follow-up letter with the results of the investigation. She further expressed that she felt staff would "blow me off" when trying to address her concerns/complaints expressed.