Pam Health Rehabilitation Hospital of El Paso

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 47893 Based on review of facility documents, observation, patient record review, and staff interview, the facility failed to follow its procedures and processes to ensure patients’ rights to report complaints/grievances; that complaints received regarding abuse, neglect, or patient harm (grievances), were self-reported to the State agency, for 2 of 2 patients (Patient #s 1 and 9); and follow up related to referral to Staff #6’s professional licensing board (Patient #9). Findings included: Review of the facility’s corporate policy, “Abuse and Neglect - Internal and External,” revised 3/20/24, documented in part, “... The hospital maintains a policy to prevent or respond to allegations of abuse, neglect, or mistreatment, and prompt reporting of any alleged abuse incident to hospital leaders and applicable state agencies. This abuse, neglect, or mistreatment may be by family ... (external abuse), or any [facility] employee (internal abuse) ... SUSPECTED ABUSE ... The hospital will follow its state guidelines for reporting, filing, and follow-up guidelines ... The hospital will report allegations, incidents, investigations, and outcomes to the appropriate agency based on state mandated reporting requirements ... The hospital will follow-up with the complainant/victim.” Review of the facility’s incident report log on the afternoon of 2/25/25, documented in part “Occurrence Category, Abuse/Neglect Reported” revealed an alleged incident, constituting abuse of patient #1 by a family member, on 1/2/25. Observation on the morning of 2/26/25, revealed a posting, “PATIENT RIGHTS AND RESPONSIBILITIES,” located in the hallway of the facility’s front entrance by which patients and visitors enter and exit, documented in part, “ ...You or your legal representative have the right to ... File a Grievance: If you want to file a grievance with this hospital, you may do so by writing or calling: Administrator: Chief Executive Officer ... You may also notify ... [the State agency department’s information was not included] ...” Review of Patient #1’s clinical record revealed a notice, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated 12/23/24, and signed by Patient #1’s [family member/representative], documented in part, “ ...You or your legal representative have the right to ... Receive care in a safe setting, free from physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective services and advocacy services including notifying government agencies of neglect or abuse ...; and ... File a Grievance: If you want to file a grievance with this hospital, you may do so by writing or calling: Administrator: Chief Executive Officer ... You may also notify ... [the State agency department’s information was not included] ...” Interview on the afternoon of 2/26/25, in a facility conference room, revealed Staff #1, Director of Quality Management, reviewed the facility’s corporate policy and confirmed that neither the facility’s posting, “PATIENT RIGHTS AND RESPONSIBILITIES” nor the signed and dated “Patient Rights and Responsibilities” form in patient #1’s clinical record included the complaint number for the State agency. There was an incident that constituted abuse, for patient #1; however, neither Patient #1 nor Patient #1’s representative were provided the number or address for the State agency, with which to file a grievance. In continuation of the interview on the afternoon of 2/26/25, in a facility conference room, Staff #1, Director of Quality Management, was asked to identify incidents of alleged abuse, neglect, or patient harm in the past year. Staff #1 stated, “We [facility] were notified of an alleged incident concerning [Patient #9] on 9/11/24. [Patient #9] was allegedly touched inappropriately by [Staff #6], who assisted [Patient #9] with a shower and wanted [Patient #9] to look in the mirror at a scar on the patient’s head, which [Patient #9] was not ready to do. We suspended [Staff #6], who held a professional license, on 9/11/24, the day we found out about the incident. Staff # 6 did not return to work at the facility. The police were informed, came to the facility, and provided a case number ... The alleged incident was not reported to [HHSC], Adult Protective Services (APS), or licensing board for Staff #6, that I am aware.” Reporting guidelines, “Provider Self-reporting,” found at hhs.texas.gov, documented in part: “ ... Licensed or certified Texas Health and Human Services (HHS) providers must notify the agency if someone in their care has been or may be physically or mentally abused, neglected or exploited” ... and reporting requirements for “General and Special Hospitals,” - “General and special hospitals must report the following incidents to HHSC (Health and Human Services Commission) within the following timeframes: As soon as possible: Abuse, neglect, or exploitation ...” The facility did not notify appropriate State agencies of alleged or suspected abuse, neglect, or exploitation for patient #s 1 and 9, as verified during an interview with Staff #1 on the afternoon of 2/26/25.”