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Based on review of policies/procedures, complaints/grievances, and interviews with staff, the hospital failed to ensure a process for prompt resolution of patient grievances for 1 of 3 sampled patients (#2).

Findings:

On 8/11/2022 at 12:34 p.m., Registered Nurse (RN) T, the Charge Nurse of Unit D-8 where patient #2 was admitted after he had a seizure in the Emergency Department (ED) on 7/05/2022 was interviewed. She stated the patient voiced concerns on 7/06/2022, soon after he was admitted to their floor that the ED did not have padded side rails raised when he had a seizure while he was in the ED. The patient fell from the bed and sustained a fall with a fibula fracture. RN T took these concerns to her Nurse Manager, RN U, Nurse Manager of Unit D-8.

On 08/11/2022 at 1:02 p.m., RN U said she met with the family on 7/06/2022 about the patient's and family's concerns related to why seizure precautions were not in place when the patient was being seen for seizures in the ED. After talking with the family, RN U brought the family's concerns to the hospital Risk Manager that same day.

The hospital's polices/procedures "Patient & Family Grievances and Complaints Policy" (Policy #RM 1.19) with last review/revised date of July30, 2022, noted that the hospital's guidelines require "a) Initial response to the patient within 7 (seven calendar) days when appropriate and b) if grievance cannot be resolved or if the investigation is not or will not be complete within 7 (seven) calendar days, the patient or the patient's representative will be notified that the hospital is still working to resolve the grievance, this is known as an extension."

Patient #2's concerns expressed on 7/06/2022 while he was a patient on Unit D-8 was never taken as a formal grievance until 8/09/2022, as confirmed in interviews with Risk Manager B on 8/10/2022 2:36 p.m., Staff C on 8/10/2022 at 2:36 p.m., who works in Risk Management related to the grievance process, and Staff S on 08/11/2022 at 9:52 a.m., the Health First System-Wide Risk Management Director, noting this grievance was not addressed within the hospital's time frames as directed in policy. The Health First System-Wide Risk Management Director stated, "That was an error on our part. The time frames are not new, and the new policy was approved on July 30, 2022."

Based on review of policies/procedures, medical records, and interviews with staff, the hospital failed to ensure 1 of 3 sampled patients received care in a safe setting after falling in the Emergency Department (ED) resulting in a fractured fibula (#2).

Findings:

Review of the "Fall Risk Assessment and Intervention Procedure (Procedure # CP 3.01.01 PRO) with the last review/revise date of 03/16/2020 noted for the "Emergency Department", "A. In order to provide for the safety of the ED Patient, an adult fall risk assessment (Morse Fall Risk Scale) . . . will be completed by the Emergency Department RN at the time of the patient's presentation to the Emergency Department. B. The determination of a high fall risk will be based upon the Emergency Department RN's assessment of the patient's presenting complaint, past medical history, and Fall Risk Assessment."

Review of the medical record for patient #2 noted the patient presented to the ED on 07/05/2022 at 4:41 p.m. via ambulance after having a seizure while at work, lasting 1 minute and witnessed by a co-worker. Review of the fall assessment (Morse Fall Risk Scale) which is a part of the ED Primary Assessment completed by Registered Nurse (RN) I on 07/05/2022 at 5:04 p.m. noted the patient's Morse Fall Risk Scale was marked as "Low Risk Level". Documentation by RN I under the assessment labeled "Special Needs" when asked "Does this patient have special needs or at risk for falls?" answered "No", despite the patient's presenting chief complaint of "seizure".

On 08/11/2022 at 10:36 a.m. and again at 2:35 p.m., RN I stated patient #2 asked to go to the bathroom and she let the patient know she was not comfortable with him walking down the hall to the bathroom due to him being there for seizure activity but would give him a urinal to use. RN I stated she assisted the patient to a sitting position on the side of the bed with the urinal in his hands and left the room to give patient privacy, stating the patient's family was in the room when she left. RN I went to another patient's room and shortly thereafter heard yelling that patient #2 was seizing again. RN I went to patient #2's room and observed the patient on the floor. She wrote in the patient's medical record, "While sitting on the edge of the bed pt. [patient] had a tonic clonic seizure and fell to the floor. Pt. hit right eyebrow, bit his tongue and lip, and . . . bleeding from the left nare. PA [physician's assistant] notified and came to patient bedside to assess. Seizure lasted approximately 30 seconds to a minute. Patient post ictal. New med [medication] order. Side rails raised and padded." Patient was admitted to in-patient status and a Computed Tomography [diagnostic imaging] of left knee without contrast was ordered after patient complained of pain 07/06/2022 with results noting a 'minimally displaced fracture of the right fibular neck with associated lipohemarthrosis'." RN I stated in hindsight, she will be documenting on the Fall Risk Assessment somewhere ensuring the patient is assessed as a high risk.

On 08/11/2022 at 11:18 a.m., when asked what standard Seizure precautions would include and be used in the ED, RN F ED Nursing Manager stated that Seizure Precautions are required in the ED with patients of suspected or known seizures and would include suction at bedside, bedrails with padding, bed in lowest position, making the patient a fall risk - in case of post ictal condition or another seizure, putting an arm band on them and placing them in a room close to nurses' station while having them on the monitor to include cardiac monitoring and vital sign monitoring.