HospitalInspections.org

Based on record review and interview, the facility failed to ensure prompt resolution of grievances, and the governing body failed to ensure the effective operation of the grievance process to review and notify complainants of the resolution within 30 days; as indicated by the facility's Complaints and Grievances policy for 1 of 1 patient (#'1) reviewed for grievances.

Specifically, Patient #1's mother/guardian/ complainant had written a grievance post marked to the facility 02/02/15. The facility's Risk Manager sent an acknowledgment letter to the complainant dated 03/08/15 (over 30 days) stating the facility would send a written response within 30 days. On 04/09/15 (over 30 days) there was no documentation that a written resolution was sent to the complainant or a completed investigation regarding her complaints and grievances.

This deficient practice affected Patient #1's rights when the facility failed to address concerns, complaints, and grievances related to the patient rights, safety, and satisfaction.

Findings included:

Record review of the facility's Patient Complaints and Grievances Policy, last reviewed 11/2013 revealed the following:

Grievances: 1.) Upon receipt of a grievance, the receiving department will indicate the date of receipt and sent the grievance to Quality/Risk Department. 2.) The Director of Risk Management or designee will investigate all grievances. 3.) A written response for the initial acknowledgment of the grievance is sent within 7 to 10 days of the person filing the grievance. 4.) A written resolution is sent within a stated number of days, but will not exceed 30 days unless notification is sent to the complainant prior to the expiration of the above stated period. The Director of Risk Management or designee will develop a written response to the patient. 5.) A copy of the completed Grievance From Written Complaint and response letter will be sent to the Chief Compliance Officer or the hospital's General Counsel for review before being mailed to the person filing the grievance.

Record review of the Department of State Health Services (DSHS) Complainant Investigative Report (TX 00212197) revealed that Patient #1's mother/guardian alleged complaints towards the facility which included a substantive quality of care issues, and a perceived violation of her daughter/patient's (#1) rights when she received services on 01/13/2015 to 01/20/2015.

Record review of the facility's Complaints and Grievances specific for Patient #1 revealed the facility had received the same alleged complaints and grievance letter (TX 00212197) towards the facility regarding her daughter's/Patient #1's care while an inpatient at the facility from 01/13/2015 to 01/20/2015. Further review revealed this letter was sent and postmarked from the sender/complainant on 02/02/2015 (over 60 days ago) to the Patient Advocate at the address of the facility that provided the services and care to Patient #1 from 01/13/2015 to 01/20/2015.

Record review of the letter provided to this surveyor from Patient #1's mother/guardian/complainant revealed a letter of acknowledgment by the facility's Director of Risk Management, dated 03/08/2015 (over 30 days from the post mark of 02/02/2015); acknowledging receipt of Patient #1's/complainants concerns. Further review revealed the concerns were received by the Quality Review Department, and the complainant could expect a written response within 30 days.

Further review of the facility's Complaints and Grievances specifically for Patient #1 revealed the facility's Risk Manager sent an acknowledgment letter to the complainant that was dated 03/11/15 (over 30 days from the post mark of 02/02/2015) that stated the facility would send a written response within 30 days. Review on 04/09/15, over 30 days from the letter sent to the complainant dated 03/08/15, revealed there was no documentation that a written resolution was sent to the complainant or a completed investigation regarding her complaints and grievances towards the facility.


During an interview on 04/08/15 at 3:50 PM with Director of Risk Management indicated she did not know exactly what day she received the complaints and grievance from Patient #1's mother/guardian regarding her daughters services from 01/13/15 to 01/20/15 but stated that Patient #1 was readmitted a second time I February (02/10/15) and, "by that time had the letter." The Director of Risk Management indicated she sent an acknowledgment letter in March 2015 and was still investigating the mother's allegations in the letter.


Further interview on 04/09/15 at 1:30 PM with the Director of Risk Management confirmed she was over the 30 days to send a written response to Patient #1's mother/guardian/complainant; in accordance with the facility's Complaint and Grievances Policy stating she missed it. The Director of Risk Management indicated she was responsible to ensure the completion and investigation of the Grievance process; and she had delegated this grievance investigation (TX 00212197) to the facility's Patient Advocate, who no longer was employed at the facility and had not completed this grievance resolution.


During a phone interview on 04/09/15 at 8:55 AM with Patient #1's guardian/mother/complainant stated she received a letter dated 03/08/2015 from the Director or Risk Management acknowledging receipt of her concerns/complaints. The complainant stated the letter indicated she would receive a written response within 30 days. Further interview revealed that the complainant had not yet received a written response regarding her alleged allegations regarding her daughter's care and services from her visit dated 01/13/2015 to 01/20/2015.

Based on record review and interview, the hospital failed to include a discharge summary with an outcome of hospitalization, a disposition of care, and provisions for follow-up care for 1 of 1 Patient (#1) reviewed.

Patient #1's discharge summary completed by the Psychiatrist did not include her newly diagnosed Diabetes Mellitus (DM) made by the Advanced Nurse Practitioner (ANP); or the follow-up care recommended for her Primary Care Physician (PCP) by the ANP.

This deficient practice could affect Patient #1's overall health by failure to follow-up and seek treatment of her health conditions.

Findings Included:

Record review of Patient #1's medical record revealed she was admitted on 01/13/15 and discharged 01/20/15 at 18:40. On 01/17/15 the facility's ANP assessed Patient #1's laboratory results for a Hemoglobin, A1C at 7.24 (normal results less than 6.5) and indicated that she had "DM". ANP documented that she would place Patient #1 on a 2000 American Diabetes Association (ADA) diet, have the dietician see patient before discharge, and documented that Patient #1 needed to follow up with her PCP.

Record review of Patient #1's Interdisciplinary Education completed by the Dietician dated 01/19/15 revealed in part; Patient #1 "is newly diagnosed with diabetes, HA1C 7.24, [Registered Dietician] RD discussed principles of a diabetic diet. Also revealed meal plan for 2000 ADA. [Patient] Pt. was responsive to information given. Provided written educational materials in chart for child/parent review upon discharge."

Record review of Patient #1's Discharge Summary dated 01/20/15 completed by the Psychiatrist revealed discharge diagnosis for AXIS III: Medical problems were- "Asthma, gastro esophageal reflux disease (GERD)." The Discharge Summary diagnosis did not include Diabetes Mellitus as diagnosed by the ANP on 01/17/15.

Record review of the Discharge Instructions dated 01/20/15 presented and signed by Patient #1's mother/guardian revealed only "Follow-up appointments" were for the Psychiatrist and Individual Therapist appointments. Further review for the area of Follow-up appointments for Primary Care Physician was documented "Deferred."

Record review of Patient #1's written complaint completed by her mother/guardian, undated, revealed when her daughter was discharged on 01/20/15; "they did blood work on her [Patient #1] and never told me she has Diabetes. My daughter told me, I confronted the nurses, they said they don't tell me; papers are sent home when she leaves; and that it's not that bad."

Record review of the facility's Medical Staff Bylaws; Rules and Regulations approved by the Board of Control May 31, 2013, revealed the following;

Where there is need of a discharge summary, a clinical resume covering the necessary
five (5) points including the final diagnosis and authenticated by the attending Practitioner
is sufficient to exclude the completion of the face sheet.
Necessary five (5) points:
(1) Why was the patient admitted?
(2) Pertinent findings.
(3) What was done? Procedures performed and treatment rendered
(4) Condition on discharge.
(5) Instructions, including medications, diet, physical activity, if any, and follow-up.

During an interview on 04/08/15 at 4:45 PM with the ANP, she stated that she diagnosed Patient #1 with DM on 01/17/15 following her laboratory test results, Hemoglobin A1C; positive for Diabetes. ANP stated she wanted Patient #1 to follow-up with her PCP following discharge because she did not want to initiate medication therapy that she was not able to monitor. ANP confirmed Patient #1's Discharge Summary and Instructions dated 01/20/15 failed to document her new diagnosis of Diabetes Mellitus and the recommended follow-up with her PCP. ANP stated that the nurse completing the Discharge Instructions did not pick that up from her record and the Psychiatrist did not add it to her final diagnosis upon discharge.

During an interview on 04/09/15 at 8:55 AM with Patient #1's mother/guardian revealed she was not told when her daughter was discharged on 01/20/15 that she had Diabetes; or that she needed to follow-up with her PCP.

Based on a record review and interview, the hospital failed to ensure that discharge instructions included the referral for follow-up care as ordered by the Advanced Nurse Practitioner (ANP) along with the necessary medical information.

Patient #1's discharge summary completed by the Psychiatrist did not include her newly diagnosed Diabetes Mellitus (DM) made by the ANP on 01/17/15; or the follow-up care recommended for her Primary Care Physician (PCP) by the ANP.

This deficient practice could affect Patient #1's overall health by failure to follow-up and seek treatment of her health conditions.

Findings included:

Record review of Patient #1's medical record revealed she was admitted on 01/13/15 and discharged 01/20/15 at 18:40. On 01/17/15 the facility's ANP assessed Patient #1's laboratory results for a Hemoglobin, A1C at 7.24 (normal results less than 6.5) and indicated that she had "DM". ANP documented that she would place Patient #1 on a 2000 American Diabetes Association (ADA) diet, have the dietician see patient before discharge, and documented that Patient #1 needed to follow up with her PCP.

Record review of the Discharge Instructions dated 01/20/15 presented and signed by Patient #1's mother/guardian revealed only "Follow-up appointments" were for the Psychiatrist and Individual Therapist appointments. The area of Follow-up appointments for Primary Care Physician was documented "Deferred." Further review revealed discharge diagnosis for AXIS III: Medical problems were- "Asthma, gastro esophageal reflux disease (GERD)." The Discharge Summary diagnosis did not include Diabetes Mellitus as diagnosed by the ANP on 01/17/15.

Record review of Patient #1's written complaint completed by her mother/guardian, undated, revealed when her daughter was discharged on 01/20/15; "they did blood work on her [Patient #1] and never told me she has Diabetes. My daughter told me, I confronted the nurses, they said they don't tell me; papers are sent home when she leaves; and that it's not that bad."

Record review of the facility's Medical Staff Bylaws; Rules and Regulations approved by the Board of Control May 31, 2013, revealed the following;

Where there is need of a discharge summary, a clinical resume covering the necessary
five (5) points including the final diagnosis and authenticated by the attending Practitioner
is sufficient to exclude the completion of the face sheet.
Necessary five (5) points:
(1) Why was the patient admitted?
(2) Pertinent findings.
(3) What was done? Procedures performed and treatment rendered
(4) Condition on discharge.
(5) Instructions, including medications, diet, physical activity, if any, and follow-up.

During an interview on 04/08/15 at 4:45 PM with the ANP, she stated that she diagnosed Patient #1 with DM on 01/17/15 following her laboratory test results, Hemoglobin A1C; positive for Diabetes. ANP stated she wanted Patient #1 to follow-up with her PCP following discharge because she did not want to initiate medication therapy that she was not able to monitor. ANP confirmed Patient #1's Discharge Summary and Instructions dated 01/20/15 failed to document her new diagnosis of Diabetes Mellitus and the recommended follow-up with her PCP. ANP stated that the nurse completing the Discharge Instructions did not pick that up from her record and the Psychiatrist did not add it to her final diagnosis upon discharge.

During an interview on 04/09/15 at 8:55 AM with Patient #1's mother/guardian revealed she was not told when her daughter was discharged on 01/20/15 that she had Diabetes; or that she needed to follow-up with her PCP.