| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670096 | (X3) Date Survey Completed 09/28/2017 |
| 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 CMS 2567 is an official, legal document. All information must remain unchanged except for entering 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 00265435 was Unsubstantiated. Complaint #TX 00266427 was Unsubstantiated. 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, Medical Staff, Nursing Services, Pharmacy Services, Discharge Planning, and Emergency Services. An entrance conference was held on the morning of 09-27-17 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 09-28-17 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 7 of 9 sampled patients with documented grievances (Patient # 13, 14, 15,16, 17,18, 19). Two(2) grievances were not investigated ; five (5) grievances: patients did not receive a written response post-investigation. Findings include: Record review on 09-28-17 of facility "Complaint List" for June through August 2017 revealed a listing of complaints by date, issue, and status. Nine (9) complaints were selected for review of facility investigation and follow-up. Two(2) complaints had not been investigated: Patient #13: on 08-07-17: complained of pain following an EGD (esophagogastroduodenoscopy) and colonoscopy. He felt he was discharged too soon. Patient # 14: on 07-27-17: complained of receiving a bill from an out-of network radiologist after he had specifically requested an in-network provider. Quality Manager # 12 was unable to provide an investigation of either of the above complaints. Five(5) complaints were investigated; facility failed to provide the complainants a written response per facility policy. Patient #15: ( 07-16-17 : dietary concerns) Patient #16: ( 08-23-17: ER provider issues) Patient # 17: ( 07-13-17: latex allergy; latex products used) Patient #18: ( 07-19-17 : contradictory radiology findings) Patient # 19: ( 06-02-17: staff behavior & attitude) Quality Manager # 12 was unable to locate the facility's post-investigation written response to the above complainants. Interview on 09-28-17 at 1:45 p.m. with Quality Manager # 12 , she stated she had very recently taken on the function of complaint investigation. She went on to say she was reviewing all the complaints and sending responses to those that had not been sent. Interview on 09-28-17 at 3:15 p.m. with Chief Executive Officer (CEO) # 1 he stated the two previous staff persons responsible for complaint investigations and follow up "were under-performers and were no longer employed by the facility." Record review of facility policy titled" Management of Patient and Family Complaints and Grievances," dated 02/2017, 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 resolve ...the hospital will follow-up with a written response within a stated number of days but no longer than thirty (30) days.." |