| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 673080 | (X3) Date Survey Completed 07/18/2024 |
| Name of Provider or Supplier Reunion Rehabilitation Hospital Plano | Street Address, City, State 3600 Mapleshade Lane, Plano, 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 | The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation (s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately. An unannounced complaint survey was conducted on site. An entrance conference was held with the hospital representatives on the morning of 7/18/2024. The representatives were informed that this investigation would be conducted according to the survey protocol in the State Operations Manual, Chapter 5, section 5100 and Appendix A, and according to 42 CFR 482 the Conditions of Participation for Hospitals. Preliminary survey findings were presented at an exit conference on the afternoon of 7/18/2024 with the representatives. They were thanked for their time and attention to the survey. The representatives were afforded an opportunity to have their questions answered and given an opportunity to provide evidence of compliance with those requirements of which non-compliance had been found. None was provided. Instructions were provided on writing plans of correction and to return the plans of correction to the Arlington zone office within 10 days. This report was electronically sent to the facility. The investigation of Complaint TX00503841 found the facility in substantial compliance with deficiencies cited. |
| A0123 | PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This STANDARD is not met as evidenced by: BASED ON record review and interview, the hospital failed to ensure the patient rights for each patient, citing 1 of 1 patients (Patient #1) did not receive written resolution of patient complaints concerning the quality of care during or after his admission in May 2024. FINDINGS There were no investigation or interventions documented through the incident report or grievance process for this patient. Patient #1 did not receive resolution of patient complaints concerning the quality of care during or after his admission in May 2024. During a record review and interview on 7/16/2024 at 1:04 PM, Personnel #2 navigated the record and confirmed the findings. The nurse note reflected on admit the wife refused staff to assess, take pictures, and dress the wounds. Personnel #1 stated there was a heated conversation with the wife. She refused pictures and did not want our nurses touching the wound. She only wanted the wound care doctor to do it. I called and asked them to come earlier. She was heightened on admission. She threw a fit that orders and meds were not immediately available. During an interview on 7/18/2024 at 3:01 PM, Personnel #3 stated there were no complaint/grievance/incident for the patient. During an interview on 7/18/2024 at 3:15 PM, Personnel #2 stated (Personnel #1's name) and I were engaged with family from the day of admission. She was anxious. She wanted to cause the same care they received at the acute hospital. She refused our interventions and wanted to direct care based on what was being done at the other hospital. We met with her and told her the care plan - she would say great and calm down. Later or another time she would be back up. Personnel #1, #2, #4, and #5 were all engaged to speak with her during her stay. During an exit conference on 7/18/2024 at 3:45 PM, Personnel #1 and #2 were asked the number of days leadership was engaged speaking with the wife. Personnel #2 stated every day. During a telephone interview on 7/19/2024 at 11:51 AM, Personnel #4 stated the wife had issues with the hospital. The hospital's 4/23/2024 last reviewed "Complaint and Grievance Management" policy required, "Processing a complaint Complaints grievance to staff members by patients, or their representatives, should be addressed in a timely manner and an attempt to resolve the issues should be made... If resolution IS ACHIEVED, the complaint is documented on the complaint/grievance form and given to the DQM for documentation purposes with no further action required... If resolution IS NOT ACHIEVED after attempts have been made to resolve the complaint, the complaint/grievance form will be completed and forwarded to DQM and/or administration for follow up as a grievance... The patient and or patient's representative will receive WRITTEN COMMUNICATION from the organization within 7 days..." |