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DALLAS BEHAVIORAL HEALTHCARE HOSPITAL LLC 800 KIRNWOOD DRIVE DE SOTO, TX 75115 Dec. 2, 2020
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on review of records and interview, the facility failed to ensure that submitted grievances were appropriately classified, investigated, and reported as grievances in 6 of 9 entries from the Complaint Log reviewed. The facility failed to follow their own policy on Complaints and Grievances.

Findings included:

A review of the Complaint Log from May 2020 to December 2020 was made on 12-2-2020. A review of the log showed that there were entries on the log that were received in writing and/or contained allegations of potential abuse, neglect, or poor quality of care.

An interview was conducted with Staff #11, Patient Advocate, at 11:45 AM on 12-2-2020 in the facility conference room. Staff #11 stated that she had received her training from the previous Patient Advocate. Staff #11 explained that if she received a complaint in writing or any other form, spoke with the complainant and explained what she intended to do, and the complainant expressed satisfaction with her intentions, then she would classify it as a complaint that had been resolved. "If I talk to them and they are happy, it's resolved."

Review of the complaint dated 11-19-2020 showed that Patient #9's mother had made allegation that the patient had been assaulted by her roommate, and other patients, and that staff would not protect her during her previous admission. The mother alleged that the patient suffered physical harm in the form of a "left black eye" that the mother alleged to have seen upon the patient's previous discharge.

During interview with Staff #11 on 12-2-2020, Staff #11 stated that she spoke with the mother, explained that the patient record did not contain information about the patient being harmed to include documentation of the patient being hit in the eye; the patient had not had a roommate; and there was no documentation of any bruising to the eye. Staff #11 stated she explained to the mother that she would notify leadership of the report so that they could investigate it. Staff #11 stated the mother was happy with her explanation and Staff #11 considered the complaint resolved.

An interview was conducted with Staff #2, Risk Management, on the afternoon of 12-2-2020. Staff #2 stated she was responsible for keeping the Complaint Log and Grievance Log current. Staff #2 confirmed that the entries listed on the Complaint Log were processed and reported as complaints. Staff #2 stated she had not reviewed November data from the Patient Advocate as it wasn't due until 12-4-2020. When asked, Staff #2 confirmed that she had received an email from the Patient Advocate regarding the complaint made by Patient #9's mother. Staff #2 had been made aware that the mother alleged the patient had been hit and not protected by staff. Staff #2 confirmed that she had not initiated an investigation into the allegations of abuse of the patient and neglect by staff.

Review of the Complaint Log showed that written and e-mail complaints were received on 11-12-2020, 11-9-2020, two (2) on 8-31-2020, and 8-27-2020. Even though they were written or were from e-mail, they were processed as complaints.

Review of the facility policy, Subject: Patient Complaints and Grievance Process, Policy # RI.1.11, Reviewed 12-13-2020 was as follows:
"DEFINITIONS:
A. 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 (CoP) or accreting organization standards, or a Medicare beneficiary billing complaint related to rights and limitations.

...

C. A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or his/her representative regarding the patient care provided, abuse and neglect, or the hospital's compliance with CoPs.

D. Letter, e-mail or fax is considered written.
....

PROCEDURE:
...
G. All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance that requires immediate attention. The Patient Advocate will forward such complaints to the Risk Management Department where a full investigation will be conducted.
...
I. All grievances receive immediate priority and must be investigated with efforts made towards resolution within 24 hours. If a grievance cannot be resolved within 24 hours, the grievance will be referred as described below. This organization will make every attempt to provide a response within seven (7) days of receiving a grievance."