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Based on interview and medical record review the facility failed to investigate a verbal grievance related to inappropriate restraint use for one (#3) of 12 sampled patients. This practice does not provide for the opportunity to identify areas to improve care

Findings:

Patient #3 was admitted to the facility on 5/27/11 for abdominal pain. The patient had surgery on 5/29/11. On 5/31/11 at midnight, nursing notes revealed the patient became agitated, disoriented and tried to get out of bed. Nursing note dated 6/1/11 at 12:21 p.m. revealed the patient was confused and trying to get out of bed. The patient was brought to the nursing station in a recliner for closer observation. Review of nursing note at 6:13 p.m. revealed the patient remained confused, agitated and tried to get up out of bed. The patient was at the nurses' station. At 6:14 p.m. the patient was returned to his room and family was at bedside. There were no further nursing notes until 8:00 p.m. shift assessment.

A verbal grievance was made to the Director of the Unit in regards to the family member finding the patient in an inappropriate restraint. The Director of the Unit was interviewed on 7/6/11 at 11:35 a.m. She stated that she received a phone call from the family member who stated a fixed restraint with a sheet was placed on the patient. She stated she spoke with several nurses and the patient was brought to the nurses' station because he attempted to get up out of bed. She stated she could not confirm the allegation of a sheet restraint. She stated she did not remember the names of the nurses she spoke with. She could not offer any documentation as to what type of investigation was done on the verbal complaint or if any education was completed.