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BAYLOR SCOTT & WHITE MEDICAL CENTER- COLLEGE STATI 700 SCOTT & WHITE DRIVE COLLEGE STATION, TX 77845 Feb. 25, 2020
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on documents review and interviews, the facility failed to follow the established Patient Complaint/Grievance policy.

Review of the facility complaint/grievance log revealed an entry on 01/15/2020 where patient # 1 family member addressed a concern after patient # 1's oxygen saturation decreased during a procedure requiring the physician to use tactile stimulation to resuscitate the patient. The family member stated the patient received a facial bruise because of the tactile stimulation. This was entered and addressed as an "Assistance Needed." The facility's response to this issue was entered as follows: "PR checked on patient's wellbeing and spoke with patients son. PR left contact information with son for any questions or concerns."

Review of a document provided by the facility revealed a timeline regarding this entry. On 1-14-2020 at 4:20 p.m. an incident report was entered into the facility's online incident tracking system. On 1-15-2020 in the morning the patient relations department was notified of the incident and rounded on the patient and contacted the patient's family by phone. A voicemail message was left. On 1-16-2020 patient relations rounded on the patient again and met with the family member and listened to his concerns. The family member requested to give consent to another family member to discuss patient # 1 condition. The offer was made by patient relations to set up a meeting with administration and patient # 1's family and the family declined at that time. Patient Relations left contact information should the family have any further concerns or questions. The family member did request to discuss the incident further with the Chief Nursing Officer and the Unit Nursing Director. The family member requested the treating physician be removed from patient # 1's case. It was again offered for administration to meet with the family and this request was again declined by family. Patient # 1 was discharged to a nursing facility in the afternoon, per the family's request.

Review of the facility's policy titled "Patient Complaints and Grievances," defines a complaint as :"A verbal expression of dissatisfaction by a Patient with the care or services received," and a grievance as: "A formal or informal written or verbal complaint that is: Made to BSWH by a patient, or the patient's representative; and regarding the patient's care (when the Complaint is not resolved at the time of the Complaint by staff present), abuse or neglect, or issues related to the facility's compliance with the Centers for Medicare and Medicaid Services ("CMS") Conditions of Participation ("CoP"). Requested by the patient, or the patient's representative, to be handled as a "Grievance." Further review of this policy does not address which definition "Assistance Needed," would fall under.

Review of section titled "Procedure-Resolution and Notification: BSWH attempts to resolve Complaints and Grievances as soon as feasible. BSWH will coordinate a resolution with the involvement of appropriate departments and/or individuals. The resolution may include: Facilitating communication between the patient and the healthcare provider/team; Assisting the patient in obtaining services; Initiating a review by the Medical Director, Department Chairperson, or designee and/or; communicating the next step. Grievances: If the grievance will not be resolved, or if the investigation is not or will not be completed within seven (7) business days, the facility should inform the Patient that BSWH is still working to resolve the Grievance and provides the approximate time period in which BSWH will be following up with a written response. The Patient's Grievance may be acknowledged by verbal or written communication within seven (7) business days from the date that the Grievance was received. The Patient is updated, generally, at the end of each thirty (30) business day period until a resolution is reached. If BSWH is unable to contact the Patient, attempts made including date and time will be documented." The facility did not address the "concerns" of patient #1's medical care as a complaint or grievance as required by their policy.

A confidential interview was conducted. It was stated the facility informed the patient's family they would investigate the incident and communicate the findings of that investigation to the patient's family. The question was asked if the concerns were resolved during the conversations with hospital staff prior to the patient's discharge, the answer was "no, and there has been no further communication from the hospital regarding the investigation of the incident."

An interview was conducted with Staff #4 on 02-25-20 at 1:30 p.m. Staff # 4 was asked why the family's concerns were not handled according to the facility policy. Staff #4 stated they felt the issue was resolved by removing the physician from the patient's care team, that addressed the family's concerns, and that the family had refused multiple attempts for a meeting with administration, and other attempts as resolution. Staff # 4 was asked if there has been any further contact with patient # 1's family and she answered no.