| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670096 | (X3) Date Survey Completed 02/02/2017 |
| Name of Provider or Supplier Bay Area Regional Medical Center, Llc | Street Address, City, State 200 Blossom Street, Webster, TX | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| A0000 | Note: The CMS567 is an official, legal document. All information must remain unchanged except for e-2ntering the plan of correction, correction dates, and the signature space. If information is inadvertently changed by the provider, you should notify the state Survey Agency. If information is inadvertently changed by the provider, you should notify the state Survey Agency. If the SA notices any discrepancy in the information, the Regional Office will make a referral of possible fraud to the Office of the Inspector General (OIG). Complaint # TX 00250740 was Substantiated and Cited. An unannounced visit was made to conduct a complaint survey per Sections 5040, 5130 and 5210F of the State Operations Manual (SOM). Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals was utilized to determined hospital's compliance with 42 CFR 482 Conditions of Participation (CoP) for Hospitals regarding:Patient Rights, Quality Assessment/Performance Improvement, Nursing Services, and Discharge Planning. An entrance conference was held on the morning of 02-02-17 with key administrative personnel. The purpose, scope and process of the complaint survey was explained and an opportunity for questions and discussion was provided. An exit conference was held on the afternoon of 02-02-17 with key administrative personnel. Findings of the investigation were discussed and again, an opportunity for questions and discussion was provided. |
| A0122 | PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This STANDARD is not met as evidenced by: 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.." |