HospitalInspections.org

Based on interview and record review, the facility failed to investigate a significant patient/family grievance per their established policy. [Citing Patient # 6]

Findings include:

TX 00262100

Record review of complaint intake # TX00262100 read : "On Saturday 01-28-17, my dad (Patient # 6) was due to be discharged to a rehabilitation hospital. My sister was with him all day and he was acting out of sorts. We are very familiar with this behavior, as in the past, failure to get his Benzodiazipine (Xanax) resulted in similar behavior.." My sister questioned staff and was told Patient # 6 had received his dose (Xanax)."Upon discharge...he suffered a tonic clinic seizure...very typical of Benzo withdrawal-this happened in the ambulance on the way to the rehabilitation hospital..."

"He was taken to an acute hospital ER where they performed a urinalysis and found no evidence of benzos in his system..." Complainant documented she "suspected a diversion (drug) and contacted the facility by telephone on two occasions (floor supervisor and administrator) and received no response..."

Interview on 06-20-17 at 1:15 p.m. with Administrative Assistant # 8 she stated she had worked in the facility for several years and was the Chief Executive Officer's (CEO) administrative assistant. She was asked if she was familiar with Patient # 6's name ; she said she was not. Administrative Assistant # 8 was informed the complainant stated she had called the facility and spoken with the CEO's assistant about concerns with her father's care. The time period was the end of January; first 2 weeks in February, 2017. Administrative Assistant # 8 said she would check her email, as that is how she would have documented the issues.

Record review of email dated 02-10-17 [written by Administrative Assistant # 8 and sent to Administrator # 1 and former Chief Nursing Officer (CNO) # 9 ] read: " ... daughter of former patient ( Patient # 6-discharged about 2 weeks ago) called and would like someone to call her back re: an issue with her father. She said she "hadn't' heard from anyone." She said that she had talked with a charge nurse after her father was discharged.... Father was transferred by ambulance to ( rehabilitation hospital) and may have had seizure. May not have been given "benzos" by nurse...she said she needs to know what happened. She mentioned she worked in healthcare".

Record review of facility's Complaint/Grievance log for 2017 failed to reveal a documented grievance by the family of Patient # 6.

Interview with Quality Coordinator # 3 on 06-20-17 at 2:45 p.m., she stated she had access to the former CNO's computer hard drive and email. She was unable to locate any documentation related to the complaint concerning Patient # 6.

Interview on 06-20-17 at 3:00 p.m. with current CNO # 2 she stated she had begun her position as CNO in late February. Surveyor provided details of the complaint, which corresponded exactly to the facility email, dated 2-10-17. CNO # 2 went on to say this complaint should have been investigated and Patient# 6's daughter should have received a return telephone call.

Review of facility policy titled "Complaint/ Grievance", dated 12-2007, read: "...III. Definitions:...C. Grievance ...a grievance is a written ( formal or informal, including email and faxes)...regarding the patient's care, abuse or neglect, the hospitals compliance with Conditions of Participation ...IV. Procedure: 2. Management of Grievance: a., If complaint is not resolved promptly, it became a grievance. B. This usually involves patient care issues..3. Grievance Investigation: .the investigation will begin immediately upon notification to the Director of Quality Services...Interviews are conducted...factual information is gathered. Applicable regulations, laws and policies are reviewed ...the grievant should be notified within seven (7) calendar days that the grievance has been received and an investigation is in progress...a written outcome letter of the hospital's decision regarding the grievance should be sent no later than thirty (30) days after the complaint is received..."