HospitalInspections.org

Based on interview and record review the facility failed to adhere to its grievance policy for 1 of 3 sampled patients with documented grievances (Patient # 13).

Patient # 13 submitted a complaint to the facility on 10-27-16 and he did not receive a written response from the facility.

Findings include:

TX 00250740

Record review of complaint intake # TX00250740 revealed documentation by Patient # 13 of multiple care and treatment issues experienced at the facility in October 2016. These allegations included: problems and a delay with nurses starting the intravenous (IV) line; improper discussion of patient health information; pain management; and discharge planning. Patient # 13 stated he had spoken with several representatives from the hospital and was assured he would receive a letter regarding the investigation findings.

Telephone interview on 02-01-17 at 1:45 p.m. with Patient # 13 he stated he had not received a letter from the hospital, although he had been told by hospital staff that he would.

Record review on 02-02-17 of the facility complaint investigation file for Patient # 13 revealed documentation by Chief Operating Officer (COO) # 4, dated 10-27-16. This documentation included specific details of Patient # 13's three (3) concerns: IV issue; HIPAA [Health Insurance Portability & Accountability Act-private health information issue]; and Discharge Planning Issue.

Interview on 02-02-17 at 2:30 p.m. with COO # 4 he said he spoke by telephone with Patient # 13 during the week of 10-31-16. Patient # 13 relayed his 3 concerns as: IV issues (delay and problems starting); personal health information shared; and discharge planning issues. COO # 4 said shortly after this call, he spoke with the Chief Nursing Officer (CNO) # 2 in the hallway and shared Patient # 13's concerns. The CNO was to address the clinical issues. He went on to say they each began investigating different portions of the complaint. COO # 4 said the complaint should have been entered into the "Quantros" computer system and it was not. CCO # 4 said because of this oversight, the complaint timeframes were not tracked. "We missed our 30 day timeframe; this fell off the radar."

Interview on 02-02-17 at 2:40 p.m. with CNO # 2 she said she remembered this patient well. When the COO informed her of the patient's issues, she telephoned Patient # 13 right away. She went on to say she investigated the nursing care concerns, including the IV delay and the discharge planning issues.

Record review on 02-02-17 of facility's documentation revealed the facility fully investigated Patient # 13's concerns but failed to provide him a written response of the investigation. The facility had drafted a response letter to the patient dated 02-02-17.

Record review of facility policy titled" Management of Patient and Family Complaints and Grievances," dated 11/2015, read: " ...D. Review, investigation and resolution of patient grievances ...d. if the grievance will not be resolved , or if the investigation is not or will not be completed within seven (7) days, the hospital will inform the patient...the hospital is still working to resolved ...the hospital will follow-up with a written response within a stated number of days but no longer than thirty (30) days.."