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Based on record review, interview, and policy review, the hospital failed to ensure the supervisor investigated and made an attempt to resolve one patient's grievance (Patient (P) 3) of three patients who requested to file a grievance. This failure had the potential to affect all patients who request to the file a grievance at the facility.

Findings include:

Review of the policy titled, "Patient Grievance" effective date 10/06/22, revealed, " ...Concerns that cannot be resolved by staff present at the time the complaint is made are considered grievances and are referred to the Supervisor, Charge Resource Nurse, or Manager for investigation and attempts at resolution. When an employee receives a concern that constitutes a grievance, he/she addresses the issue promptly and notifies the next person in chain of command."

Review of P3's electronic medical record (EMR) revealed P3 arrived at the emergency department (ED) on 06/11/24 at 1:56 PM with a chief complaint of "general checkup."

Reveal of the triage nurse note located in P3's EMR dated 06/11/24 at 2:11 PM revealed, " ...Pt arrived to [sic] triage with co [complaint] of needs total checkup, requesting CT [Computerized Tomography] scan of body. Pt states have chronic pain /Pt uses cane for ambulation at all times Pt states central area chronic chest pain and abdominal pain for one year. Pt complaints of generalized body aches, lower back pain, wearing sling on right arm ...Pt denies any SOB, nausea, vomiting or dizziness at this time ...Pt states taking Advil and pain is not well controlled at this time. Pt with edema on bilateral legs at this time HX [history] of BP[ high blood pressure], diabetes, elevated cholesterol."

Review of P3's EMR dated 06/11/24 at 2:20 PM revealed, "Acuity/Destination Patient Acuity: 3
Triage Complete."

Review of the "ED Quick Updates" dated 06/11/24 at 8:50 PM located in P3's EMR revealed, "Patient came up to RN [Registered Nurse] asking why the wait is so long. RN explains to patient that everyone is waiting for a room in the back to see a doctor. Patient states she has not eaten all day and needs something to eat. RN provided patient crackers and water."

Review of the "ED Quick Updates" dated 06/11/24 at 9:30 PM located in P3's EMR revealed, "Patient's spouse came up to front desk asking, 'what is taking so long'. RN explained to escort that the patient is waiting for a room in the back to talk with the doctor about [his/her] results from lab work and imaging. Escort asks RN 'How do we make this go faster.' RN explained that it is a process and is based on the acuity of the patient and how critical everyone is. RN [not] able to provide an exact time to escort."

Review of the "ED Quick Update" dated 06/11/24 at 11:24 PM located in P3's EMR revealed, " ...Patient came up to the front window yelling at triage nurse. Patient screams "I need a form to make a complaint!" [name] RN explains to patient that we do not have a form but gave the number to patient relations to have the patient call that number ...RN explains that we [hospital] do not have a form system, and you have to call this number to file complaint. Patient is upset and states that she wants to see an administrator ... called lead charge to have her come up. ..."

Review of P3's EMR did not reveal a Supervisor, Charge Resource Nurse, or Manager responded to P3's request to speak to someone concerning his/her complaint of a long wait time to be seen.

During an interview on 11/19/24 at 8:00 AM, the Corporate Director of Emergency Services (CDED) stated, "grievances go to me or the lead charge nurse." CDED confirmed P3's EMR did not include documentation the Lead RN spoke to the patient on 06/11/24 or that a grievance was filed.

During an interview on 11/19/24 at 11:00 AM, Registered Nurse (RN) 2, who was the Lead RN on duty on 06/11/24, stated he/she did not recall any notification from RN5 that P3 complained about a long wait time in the ED and wanted to speak to someone in administration. RN 2 stated if notified, documentation in the medical record would include that the patient was seen and Patient Relations notified to either meet face to face with the patient or open a grievance.

Based on record review, observation, interview, and policy review, the hospital failed to ensure an adequate basis for the use of a restraint and failed to ensure the least restrictive intervention was implemented for one (Patient (P) 25) of three patients reviewed for use of a restraint. This failure had the potential to affect all patients who may require the use of a restraint at the facility.

Findings include:

Review of the facility policy titled, "Restraint Seclusion and Safety Devices" effective 09/23/24 revealed, "Alternatives and Preventive Strategies to Use of Restraints: A. Alternatives are considered before using restraints on any patient and particularly ...vulnerable patients, such as emergency, pediatric, or cognitively and/or physically limited patients. B. Alternatives may include but are not limited to the following methods: direct observation, family/friend attends/sits with, verbal interventions/de-escalation/re-direction, environmental measures, (relaxing music, lighting, decrease stimulation, place near nurse's station) use of bed check alarm, comfort measures (pain management, positioning), Medical nutrition (discontinue unnecessary lines), Structure/limit setting activities, noise control, and diversional activities ...A restraint is only used if needed to improve the patient's well-being and less restrictive interventions have been ineffective to protect the patient or others from harm ...Restraints are not a routine part of a fall prevention program ...."

Review of the facility policy titled, Special Observation: Safety Attendant, Patient Observer and Virtual Sitter Roles" Effective Date: 07/11/24 revealed, " ...4. Order Virtual Sitter when a patient requires remote continuous monitoring. Place patient in a room equipped with video surveillance capability. Circumstances for virtual sitter may include, but are not limited to:
A. Risk for falls
B. Confusion
C. Unilateral weakness
D. Patient safety
E. Patient with substance use disorder
After the order is placed, the patient's name appears on the worklist to initiate monitoring. ..."

Review of P25's electronic medial record (EMR) revealed P25 was admitted to the facility on 06/17/24 with diagnoses of dementia with behaviors, hypernatremia, diabetes mellitus, risk for falls, and depression.

Review of the "Morse Fall Risk Assessment" dated 11/05/24, located in P25's EMR revealed a score of 65 which indicated P25 was a high risk for falls. Review of the "Morse Fall Risk Assessment" dated 11/06/24 through 11/18/24 revealed P25 was a high risk for falls.

Review of the "Care Plan" dated 11/05/24 located in P25's EMR revealed risk for falls with interventions to provide environmental measures (relaxing music, lighting), use of bed check alarm, chair alarm, direct observation, verbal intervention, and comfort measures (pain management and positioning).
Review of the "Shift Report" dated 11/05/24 at 6:56 PM located in P25's EMR revealed, " ... patient fairly cooperative during the morning and early afternoon but had increased behaviors as the day went on. Yelling constantly for help, trying to get up without assistance, becoming more agitated and defiant with certain staff members, and minimally redirectable ...."

Review of the "Assessment" dated 11/05/24 at 7:04 PM located in P25's EMR revealed, "aggressive, agitated and repeated attempts to get oob/chair."

Review of the "Nurse's Note" dated 11/05/24 at 7:40 PM located in P25's EMR revealed, " ...received report from day RN patient attempts to get out of chair with alarm on. Vest restraint placed on pt [patient] for safety. Safety measures in place with chair alarm on including vest ...Provider notified."

Review of the "Orders" dated 11/05/24 through 11/18/24 located in P25's EMR revealed, " ...Restraint nonviolent or non-self-destructive: Restraint type: Vest ... Continuous up to 1 calendar day ...Remove restraint at the earliest possible opportunity ...Restraint reason: interferes with necessary treatment, is unable to follow directions to avoid self-injury ...."

Review of the Nurse Practitioner note "Summary Restraints" dated 11/05/24 at 7:04 PM located in P25's EMR revealed, " ...patient has a history of dementia, TBI (Traumatic Brain Injury/2003) ...The nurse reported that the patient has had multiple attempts to get out of bed, not following instructions, unable to keep patient in the chair, and is high risk for falls. Patient placed in posey vest for patient safety ...Face to face completed. Patient is alert and oriented x 3 and pleasant. Nursing instructed to removed posey vest as soon as its safely possible and have safety measures in place. Patient sitting in reclining chair with posey vest in place at the entrance to his room. We will monitor behavior closely, try to remove posey vest ASAP and adjust treatment plan as indicated ...."

Observation on 11/18/24 at 1:30 PM revealed P25 was in a private room, in bed with the bed in a position that was not in view from the door. P25 was observed with a vest restraint on over a johnnie gown. An overbed table was in front of the patient. The television in the room was not turned on. There wasn't any diversional activity equipment observed in the room.

Review of the nurse "Assessments" located in P25's EMR revealed every two hour assessments were conducted by nursing while P25 had the vest restraint in use. Review revealed "television" was the only alternate intervention identified as being used.

Review of the "Provider Notes" located in P25's EMR revealed a "Face to Face" was conducted by a provider every 24 hours during the use of the vest restraint.

During an interview on 11/20/24 at 10:00 AM, the Corporate Director of Critical Services (CDCS) stated that per hospital policy, before nonviolent restraints are used because a patient cannot follow direction, alternate measures are implemented. Measures can include busy blanket, recreation therapy, being near the nurses station, television, and chair/bed alarms. CDCS confirmed that because a patient was a fall risk is not a reason to initiate a restraint. Extra watching/surveillance can used and any interventions I mentioned. CDCS stated P25 had the "virtual sitter" as an intervention in the past and could not explain why the intervention or others were not attempted before the use of the vest restraint on 11/05/24.