Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 670024	(X3) Date Survey Completed 04/12/2011
Name of Provider or Supplier North Cypress Medical Center	Street Address, City, State 21214 Northwest Freeway, Cypress, 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)

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 facility failed to implement it's grievance policy dated January 2010 to resolve patient complaints concerning quality of care and to inform them in writing the steps that were taken to investigate and resolve the complaint. The facility did not respond in writing to a family's complaints, citing one patient identified in a complaint TX 00142246. (Patient # 1). Findings: Review of complaint narrative written by Complainant J, on behalf of patient # 1 revealed the complainant had the following care concerns: (a) Ninety eight (98) years old Patient #1, was given the drug Morphine(pain medication) which had a as needed (PRN) order without the patient asking for pain medications, as a result the patient became very drowsy and dizzy. According to the complainant the facility did not use good judgement. (a) Staff did not respond in a timely manner when the patient called for assistance to the rest room. (c) the patient fell out of bed and the bed alarm was not activated although the patient was labeled "high risk for fall". (d) Complainant spoke to several different staff who told her they would look into her concerns,but no one ever responded. During a telephone interview on 4/11/11 at 2:30 pm with complainant J, she stated she spoke with administrative staff regarding her concerns but to date no one had responded to her concerns. Review of the hospitals complaint records revealed no documentation that the complainant had voiced concerns regarding the care and services patient # 1 received. Review of admission record for patient # 1 revealed she was admitted to the facility on February 2011 and again in March 2011. Review of nurses notes dated 2/11/11 revealed documentation that the "patient's niece had concerns regarding medication that her aunt was given because she was more confused as compared to earlier". Further review of progress notes and nurses notes for the February and March admissions revealed no documentation in the patient's record that patient or family had other care concerns. Review of nurses notes dated February 15, 2011 revealed documentation that Staff # 50, "Chief Nursing Officer(CNO) was in the patient's room talking to her niece" During the investigation the Surveyor verified that Complainant J discussed her concerns with unit and administrative staff,however no one responded to her concerns. During an interview with Staff # 51, Quality Coordinator she stated Ms. J, ( Complainant) had a discussion with her regarding her dissatisfaction with the nursing staff giving Patient # 1 Morphine when it was not indicated. According to Staff # 51, the complainant stated she felt Morphine was given to the patient to keep her sedated so staff would not have to take her to the rest room during the night. Staff # 51 also stated the complainant told her that staffs were also putting the patient in diaper and her aunt never wore diapers before. During an interview on 4/12/11 with Staff # 52, Nursing Director she stated she remembered having several discussions with Patient # 1's niece who had concerns regarding her Aunt ' s care. During an interview on 4/12/11 at 11:45 am at the facility with Staff # 50 (CNO) she stated Complainant J , made a complaint to her, that the patient was given Morphine which made her dizzy and that she was never given morphine for her pain before and that the patient did not ask for any pain medication. According to Staff # 50 she investigated and found there was a PRN (give as needed) order for the morphine. There was also documentation that the patient was in pain. The CNO further stated she did not document the complaint or the investigation and did not respond to the complainant in writing because the patient was an in- patient and the concerns were not considered a grievance. Review of the facility's grievance policy dated January 2010 revealed that: "A patient grievance is a formal or informal written or verbal complaint that is made when a patient issue cannot be resolved promptly "on the spot" by staff present. Within 7 days of the grievance , a letter will be submitted to the complainant that includes results of the grievance investigation, corrective action as necessary." The facility failed to respond to Complainant J in writing.