Roger Williams Medical Center

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 43881 Based on clinical record review and staff interviews, the hospital failed to meet §482.22, Condition of Participation: Medical Staff after the following was identified: The hospital failed to ensure Emergency Department (ED) physicians adhered to the hospital’s Emergency Department process requiring documentation of preliminary (“wet read”) X-ray interpretations during overnight hours (10:00 PM through 7:00 AM). This failure was identified in 6 of 6 patient records reviewed (A-0347). The hospital failed to ensure physicians on the geriatric psychiatric unit and the medical step-down unit were aware that a physician’s order was required in the patient’s clinical record for use of the Blanketrol III cooling blanket system, including specific instructions for temperature settings, duration of therapy, and frequency of skin checks, in accordance with the manufacturer’s instructions. As a result, a patient was placed on a cooling blanket following a verbal order, without a corresponding physician’s order entered into the clinical record specifying temperature settings, duration of therapy, and frequency of skin checks. This failure resulted in an Immediate Jeopardy (A-0353). Findings are as follows: A Centers for Medicare/Medicaid Service (CMS) authorized Federal substantial allegation survey was conducted from 1/15/2026 through 1/29/2026 at Roger Williams Medical Center to determine compliance with §482.22, Condition of Participation: Medical Staff. It was determined that the hospital was not in substantial compliance with the requirements of §482.22 Condition of Participation: Medical Staff after the hospital failed to ensure physicians on the geriatric psychiatric unit and the medical step-down unit were aware that a physician’s order was required in the patient’s clinical record for use of the Blanketrol III cooling blanket system, including specific instructions for temperature settings, duration of therapy, and frequency of skin checks, in accordance with the manufacturer’s instructions. As a result of the identified non-compliance, Patient ID #10 was placed on a cooling blanket following a verbal order, without a corresponding physician’s order entered into the clinical record specifying temperature settings, duration of therapy, and frequency of skin checks. The hospital was informed of the Immediate Jeopardy and was provided with the Immediate Jeopardy template on 1/22/2026 at 1:01 PM, after it was identified. On 1/23/2026, the hospital submitted an Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented: 1. A blast e-mail will initially be sent out 1/22/26 to all medical residents and hospitalists advising physicians of issues identified. 2. The e-mail will also include Equipment manufacturer guidelines that must be utilized and followed when using the equipment. Included in the e-mail previously mentioned, a set of guidelines for clinical reference will be included and advise staff on: - Need for a written MD order to implement the use of the equipment and clinical parameters should be included in the order - When to contact the MD - Physicians will read the e-mail and sign an attestation and return the attestation to the Chief Resident to be completed by 1/23/2026 On 1/27/2026 at approximately 2:40 PM, the State Survey Agency confirmed that the IPOC stated above was implemented. 45769”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 43881 Based on clinical record review and staff interviews, the hospital failed to meet §482.23 Condition of Participation: Nursing Services after the following was identified: Nursing staff on the geriatric psychiatric unit and the medical step-down unit overseeing a patient’s care failed to check the patient’s skin integrity and body temperature in accordance with hospital guidelines and manufacturer’s instructions (A-0398). Nursing staff failed to re-measure wounds weekly and on the day of discharge in accordance with hospital policy (A-0398). Nursing staff failed to implement interventions addressing sensory perception, moisture, activity, mobility, nutrition, and friction and shear in accordance with hospital policy and guidelines for patients identified as high risk (Braden score of 11 or less) or severe risk (Braden score of 9 or less) (A-0398). Findings are as follows: A Centers for Medicare/Medicaid Service (CMS) authorized Federal substantial allegation survey was conducted from 1/15/2026 through 1/29/2026 at Roger Williams Medical Center to determine compliance with §482.23 Condition of Participation: Nursing Services. It was determined that the hospital was not in substantial compliance with the requirements of §482.23 Condition of Participation: Nursing Services after nursing staff on the geriatric psychiatric unit and the medical step-down unit failed to follow hospital guidelines and the manufacturer’s instructions for use of the Blanketrol III, a cooling blanket system utilized to normalize a patient’s body temperature. As a result of the identified non-compliance, Patient ID #10 was placed on a cooling blanket following a verbal order, without a corresponding physician’s order entered into the clinical record specifying temperature settings, duration of therapy, and frequency of skin checks. Consequently, nursing staff overseeing the patient’s care failed to check the patient’s skin integrity and body temperature in accordance with hospital guidelines and manufacturer’s instructions. The hospital was informed of the Immediate Jeopardy and was provided with the Immediate Jeopardy template on 1/22/2026 at 1:01 PM, after it was identified. On 1/23/2026, the hospital submitted an Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented: 1. A blast e-mail will initially be sent out 1/22/26 to the all units advising staff and leaders of the issues identified. 2. The e-mail will also include equipment manufacturer guidelines that must be utilized and followed when using the equipment. Included in the e-mail previously mentioned, a set of guidelines for clinical reference will be included and advise staff on: - Need for an MD order to implement the use of the equipment and clinical parameters - Frequency of monitoring VS and other clinical indicators - When to contact the MD - Staff will read the e-mail and sign an attestation and return the attestation to the unit Director/designee before going back to their assignment Via e-mail and during in-person education, Staff will be advised that if they have not completed the education, they are not allowed to use the equipment until contacting their unit leadership, nursing supervisors or the education department to assure that the equipment will be utilized correctly according to manufacturer recommendations and hospital approved guidelines. An e-mail will go out to nursing supervisors informing them that staff not educated on the equipment will not be permitted to use that equipment. The blast e-mail will be completed 1/22/26. 45769”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 43881 45769 Based on review of medical records, review of facility documents, and staff interviews, it was determined that the Hospital failed to meet §482.43 Condition of Participation: Discharge Planning after the following was identified: - The hospital failed to identify wound care instructions on the discharge summary (A-0813). -The hospital failed to ensure that follow up appointments are transcribed accurately upon discharge (A-0813). - The hospital failed to ensure that the discharge summary is thorough and concise (A-0813).”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 43881 Based on clinical record review and staff interviews, the hospital failed to ensure that Emergency Department (ED) physicians complied with the hospital’s ED process requiring documentation of a preliminary (“wet read”) interpretation of X-ray results during overnight hours (10:00 PM through 7:00 AM) for 6 of 6 patients reviewed (Patient ID #s 2, 13, 14, 15, 16, and 18). The radiologist was not aware that a preliminary interpretation had been completed by the ED physicians because the ED physicians did not document the preliminary impressions in the Rhode Island Medical Imaging (RIMI) platform as required. Findings are as follows: Clinical record review for Patient ID #s 2, 13, 14, 15, 16, and 18 revealed they were evaluated in the Emergency Department in January of 2026. Diagnostic imaging was obtained for all patients during overnight hours. All results were interpreted by ED physicians and preliminary findings were documented in the clinical records. However, the hospital failed to provide evidence that preliminary impressions were documented in the RIMI platform as required. During a surveyor interview on 1/13/2026 at 10:55 AM with the Systems Director of Diagnostic Imaging, Interventional Radiology and Cardiology, he explained that beginning at 10:00 PM each night, X-rays are initially interpreted by Emergency Department (ED) physicians, with the Radiologist completing the final official read the following morning. When an ED physician reviews an X-ray, they are required to document their preliminary interpretation in the RIMI system. The following morning, the Radiologist performs the official interpretation and can view the ED physician’s documented impressions in RIMI. If there is a discrepancy between the ED physician’s preliminary interpretation and the Radiologist’s final read, a discrepancy note is sent back to the ED physician. These discrepancies are tracked in a system that allows reports to be generated. However, he confirmed that this report did not generate any results since no ED providers had been entering preliminary impression in the RIMI system as required. He also explained that if an ED physician does not enter a preliminary impression into the RIMI system, the Radiologist does not have the ED documentation to reference during the final review, which can limit follow-up actions related to discrepancies. During a surveyor interview on 1/15/2026 at 1:30 PM with the Chief of Radiology, he acknowledged that the ED Physicians were having difficulty accessing the RIMI system to enter their preliminary reads despite receiving training on the system and confirmed that their were no preliminary reads in the RIMI system for the patients involved.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 43881 Based on clinical record review, review of the Medical Staff Bylaws, and staff interviews, the hospital failed to ensure that physicians on the geriatric psychiatric unit and the medical step-down unit were aware that a physician’s order was required in the patient’s clinical record for use of the Blanketrol III (a cooling blanket system utilized to normalize a patient’s body temperature) that included specific instructions for temperature settings, duration of therapy, and frequency of skin checks, in accordance with the manufacturer’s instructions and the Bylaws. As a result, Patient ID #10 was placed on a cooling blanket following a verbal order, without a corresponding physician’s order entered into the clinical record specifying temperature settings, duration of therapy, and frequency of skin checks for 1 of 1 patient reviewed. Findings are as follows: Record review of the “Blanketrol III Operation Manual” states in part, “Warning ... A physician’s order is required for setting blanket temperature and use of equipment. At least every 20 minutes, or as directed by physician, check patient’s temperature and skin integrity of areas in contact with blanket; also check Blanketrol III’s water temperature ...The method of temperature control provided by all hyper-hypothermia units presents the danger of heating or cooling body tissues, particularly the skin, to a point where they are injured, i.e., burns or frostbite, respectively. The clinician is responsible for determining the appropriateness of the temperature limits in dependency to time...” According to the Bylaws, “All orders for treatment shall be in writing or must be entered through the computerized order entry system...All verbal or telephone orders must be appropriately signed or electronically signed by a practitioner involved in the care of the patient no later than the end of the next calendar day...” Clinical record review revealed that Patient ID #10 presented to the hospital in November of 2025 due to severe agitation, paranoia and combative behavior. According to the clinical record, the patient was medically cleared in the Emergency Department and admitted to the Geriatric Psychiatric Unit (GPU) for further evaluation and treatment. Record review of a nursing progress note dated 1/8/2026 at 1:00 PM authored by Employee M, Registered Nurse (RN), and the vital signs record from 1/8/2026 revealed that the patient had an elevated temperature of 105.6 degrees Fahrenheit at 9:59 AM. The patient was medicated with Tylenol without effect and was subsequently transferred to the medical step-down unit due to the elevated temperature. Employee M further indicated that the patient’s temperature was monitored over a four-hour period but failed to document when the cooling blanket was started while the patient was on GPU. The patient’s temperature readings were documented as follows: - Unknown time: 102.7 degrees Fahrenheit - 12:35 PM: 103.3 degrees Fahrenheit - 12:44 PM: 101.3 degrees Fahrenheit Clinical record review of a physician progress note dated 1/8/2026 authored by Employee N, Attending Physician, indicated that the patient exhibited “increased muscle rigidity” while on the GPU. He indicated that the patient was treated with Tylenol and cooling blankets. Employee N documented concerns for Neuroleptic syndrome or serotonin syndrome which prompted transfer to the medical floor for further evaluation and treatment. Review of a nursing note dated 1/8/2026 at 6:02 PM authored by Employee H, RN, stated that the patient arrived at the medical step-down unit at 2:00 PM with a temperature of 100.9 degrees Fahrenheit. She further stated that a cooling blanket was applied to the patient “per orders.” The patient’s temperature was documented as 100.5 degrees Fahrenheit at 3:00 PM and 98.7 degrees Fahrenheit at 6:00 PM, at which time the physician was notified and the cooling blanket was removed. The clinical record failed to reveal evidence that a physician’s order was entered into the clinical record in accordance with the Bylaws and manufacturer’s instructions specifying temperature settings, duration of therapy, and frequency of skin checks. During a surveyor interview on 1/21/2026 at 3:27 PM with Employee H, RN, she indicated that she was the patient’s primary nurse when the patient arrived at the medical floor and confirmed that she did not see a physician’s order in the medical record for the use of the cooling blanket. During a surveyor interview on 1/22/2026 at 8:25 AM with Employee N, Medical Attending, he stated that both he and Employee O were present on the unit, but Employee O provided the verbal order for the cooling blanket. Employee N stated that he did not enter a written order for the cooling blanket, explaining that the situation was approached as a “wait and see if we could get a cooling blanket.” Employee N further stated “I don’t know why an order was not entered, if anything, I would say that someone should have put it in.” During a surveyor interview on 1/22/2026 at 9:24 AM with Employee O, Nurse Practitioner, she stated that she gave a verbal order for a cooling blanket because she was unsure if the unit could get it. Employee O stated that she told the floor nurse, “if we get the machine we can put in an order.” She further stated that there should be a policy to follow and that staff were instructed to contact the Intensive Care Unit if there were any questions. While reviewing the documented vital signs, Employee O stated that she believed the cooling blanket was applied at approximately 12:35 PM when the patient’s temperature was 103 degrees Fahrenheit. She stated that although she gave a verbal order to the patient’s nurse, she remained unaware of the exact time the cooling blanket was initiated. Employee O stated that the patient’s vital signs were rechecked at 12:44 PM and indicated that temperatures are required to be monitored every 15 minutes while a patient is on a cooling blanket. During a surveyor interview on 1/22/2026 at 10:40 AM with the Chief Resident, Employee Q, he stated that he believes “the nurse puts on the blanket themselves” since they “don’t usually put in an order.” He further stated, “I’ve never put in an order unless nurses directly ask me to put one in.” During a surveyor interview on 1/22/2026 at 11:00 AM with Employee R, Physician, he acknowledged that a verbal order was given for the application of the cooling blanket, however, he indicated that he did not think an order is usually entered into the medical record for the use of a cooling blanket. He stated that he has never entered orders for cooling blankets, despite its use. Employee R further stated that he did not remember being notified when the cooling blanket was discontinued nor giving an order for discontinuation. He acknowledged that he did not enter an order for the cooling blanket and that nursing staff did not ask him to enter one.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 43881 Based on clinical record review, hospital records and staff interviews, the hospital failed to ensure that nursing staff on the geriatric psychiatric unit and the medical step-down unit followed hospital guidelines and the manufacturer’s instructions for use of the Blanketrol III, a cooling blanket system utilized to normalize a patient’s body temperature. As a result, Patient ID #10 was placed on a cooling blanket following a verbal order, without a corresponding physician’s order entered into the clinical record specifying temperature settings, duration of therapy, and frequency of skin checks. Consequently, nursing staff overseeing the patient’s care failed to check the patient’s skin integrity and body temperature in accordance with hospital guidelines and manufacturer’s instructions for 1 of 1 patient reviewed. Findings are as follows: 1. Record review of the “Blanketrol III Operation Manual” states in part, “Warning ... A physician’s order is required for setting blanket temperature and use of equipment. At least every 20 minutes, or as directed by physician, check patient’s temperature and skin integrity of areas in contact with blanket; also check Blanketrol III’s water temperature ...The method of temperature control provided by all hyper-hypothermia units presents the danger of heating or cooling body tissues, particularly the skin, to a point where they are injured, i.e., burns or frostbite, respectively. The clinician is responsible for determining the appropriateness of the temperature limits in dependency to time...” Record review of the hospital’s guidelines for the use of the Blanketrol III systems stated in part to “Check the patient’s temperature and skin integrity every 20 minutes Use Distilled H2O [water] only...” Clinical record review revealed that Patient ID #10 presented to the hospital in November of 2025 due to severe agitation, paranoia and combative behavior. According to the clinical record, the patient was medically cleared in the Emergency Department and admitted to the Geriatric Psychiatric Unit (GPU) for further evaluation and treatment. Record review of a nursing progress note dated 1/8/2026 at 1:00 PM authored by Employee M, Registered Nurse (RN), and the vital signs record from 1/8/2026 revealed that the patient had an elevated temperature of 105.6 degrees Fahrenheit at 9:59 AM. The patient was medicated with Tylenol without effect and was subsequently transferred to the medical step-down unit due to the elevated temperature. Employee M further indicated that the patient’s temperature was monitored over a four-hour period but failed to document when the cooling blanket was started while the patient was on GPU. The patient’s temperature readings were documented as follows: - Unknown time: 102.7 degrees Fahrenheit - 12:35 PM: 103.3 degrees Fahrenheit - 12:44 PM: 101.3 degrees Fahrenheit Clinical record review of a physician progress note dated 1/8/2026 authored by Employee N, Attending Physician, indicated that the patient exhibited “increased muscle rigidity” while on the GPU. He indicated that the patient was treated with Tylenol and cooling blankets. Employee N documented concerns for neuroleptic syndrome or serotonin syndrome which prompted transfer to the medical floor for further evaluation and treatment. Review of a nursing note dated 1/8/2026 at 6:02 PM authored by Employee H, RN, stated that the patient arrived at the medical step-down unit at 2:00 PM with a temperature of 100.9 degrees Fahrenheit. She further stated that a cooling blanket was applied to the patient “per orders.” The patient’s temperature was documented as 100.5 degrees Fahrenheit at 3:00 PM and 98.7 degrees Fahrenheit at 6:00 PM, at which time the physician was notified and the cooling blanket was removed. The clinical record failed to reveal evidence that the patient’s temperature and skin integrity were checked every 20 minutes in accordance with hospital guidelines and the manufacturer’s instructions. During a surveyor interview on 1/21/2026 at 11:37 AM with Employee G, Clinical Nurse Manager, she confirmed that a cooling blanket was applied on the patient in the GPU after a provider gave a verbal direction to the nursing staff. She stated that an Intensive Care Unit (ICU) nurse came to the GPU to set up the cooling blanket equipment and the same nurse entered the settings. During a surveyor interview on 1/21/2026 at 1:58 PM with ICU nursing staff, Employee E and Employee F, Employee E confirmed that physician orders for cooling blankets are “not always” entered into the medical record. Employee F stated that she brought the cooling blanket equipment to the GPU after staff indicated they were looking for one and that she set up the equipment for the nurse assigned to the patient’s care. She further stated that the nurse caring for the patient indicated that this was his first time seeing and using this type of equipment. Employee F stated that she instructed the nurse to monitor the patient’s temperature every 15 minutes until the patient responded to the treatment. Employee F further revealed that a physician was present while she was explaining to the nurse how to use the cooling blanket equipment. She stated that the physician was “learning too,” and she did not want to “overstep” by providing additional instructions while the physician was present. Employee F then stated that she returned to the ICU after instructing the nurse on the GPU on the use of the cooling blanket. Employee F further confirmed that she returned to the ICU prior to the application of the cooling blanket. During a surveyor interview on 1/21/2026 at 1:29 PM with Employee D, Nurse Director, she confirmed that the hospital did not have a policy in place for the use of a cooling blanket. Employee D identified Employee M, RN, as the nurse assigned to the patient on the GPU. Employee D further stated that Employee M was told to assess the patient’s skin integrity and indicated that the patient’s temperature should have been obtained every 30 minutes after the cooling blanket was applied. Employee M was unavailbale for interview. During a surveyor interview on 1/21/2026 at 3:27 PM with Employee H, Registered Nurse, she indicated that she was the patient’s primary nurse when the patient arrived to the medical step-down unit sometime after 4:00 PM or 5:00 PM and confirmed that she did not see a physician’s order in the medical record for the use of the cooling blanket. She reported that the nurse who accompanied the patient informed her that the cooling blanket was “all set to go” and instructed her to ensure the equipment was filled with water, however, no instructions were provided regarding the type of water to be used. Employee H stated that she was told during handoff report that the patient’s temperature had been monitored every 30 minutes and that she was to obtain the patient’s temperature every two hours. She indicated that upon assuming care, the patient’s temperature was between 100 and 101 degrees Fahrenheit. She stated that two hours later, she rechecked the patient’s temperature, found that it was normal, and the patient’s skin was cold. She then notified the physician and removed the blanket. Employee H stated she informed the oncoming nurse that the cooling blanket equipment remained in the patient’s room and told the nurse to reapply the cooling blanket if the patient’s temperature increased. Employee H stated she has been employed by the facility since June of 2025 and had not previously used this type of cooling blanket equipment and confirmed that she did not receive education or training on the use of this equipment during orientation. Employee H further stated that the nurse who provided a handoff report gave her a “crash course” on the use of the equipment indicating that he had not previously used the equipment himself. 2. Review of a hospital policy titled, “Skin Care Protocol: Prevention, Treatment, and Use of Pressure Relief devices” last reviewed on 2/1/2024, states in part, “Assess pressure injuries ...Include the wound measurements and then re-measure weekly and the day of discharge ...” Record review for Patient ID #1 revealed she/he was admitted to the hospital in November of 2025 with a diagnosis of aspiration pneumonia (infection caused by inhaling food, liquid, saliva or other contents into the lungs) and was treated with intravenous antibiotics. While at the hospital, Patient ID #1 was noted to develop a wound on his/her sacrum (the triangular bone at the base of the spine) and a physician’s order for a wound consultation was provided on 12/18/2025. Record review of a Wound Specialist Note authored by Employee I with a documentation date of 12/18/2025 indicated that an assessment of the wound on Patient ID #1’s sacrum was conducted and documented as follows: “Patient noted to have a stage II [damage to the skin that results in the loss of the outermost layer (epidermis) and exposure of the dermis, which is the middle layer of skin. This type of ulcer presents as a shallow, open wound with a pink or red wound bed] PI [pressure injury] measuring 1 x 0.9 x 0.1 cm [centimeters] of the right side of sacrum. There is no fluctuance erythema or increased temperature please reposition with consideration of pressure injury, and protect with moisture barrier from incontinence...” Review of the Pressure Injury Assessment revealed that on 12/18/2025 Patient ID #1 had a stage II wound to his/her sacrum documented. Further review of the medical record from 12/25/2025 through 1/8/2026, the date of discharge, failed to reveal evidence that the stage II PI on Patient ID #1’s sacrum was re-measured weekly and on the day of discharge per the hospital’s policy. Additional review of the Pressure Injury Assessment revealed that on 12/31/2025, Patient ID #1 was documented as having a stage II PI to his/her scrotum. Further review of the medical record from 12/31/2025 through 1/8/2026, the date of discharge, failed to reveal evidence that the stage II PI on Patient ID #1’s scrotum was measured when discovered and on the day of discharge per the hospital’s policy. During a surveyor interview with the Wound Specialist, Employee I, on 1/27/2026 at approximately 1:45 PM, she revealed that she saw Patient ID #1 on 12/18/2025 regarding his/her sacrum wound. Additionally, she indicated that she implemented treatments for the sacrum stage II PI. Staff I further revealed that once she implements treatment for a patient, she does not continue to follow them, unless another consultation is requested, and that it is the floor nurse’s responsibility to measure the wounds. Lastly, Employee I revealed that she was not contacted or made aware that Patient ID #1 had developed new pressure area on his/her scrotum. Record review for Patient ID #9 revealed she/he presented to the hospital in November of 2025 for progressive catatonia (inability to move normally) and mutism (inability or unwillingness to speak). While at the hospital, the patient was noted to have a deep tissue injury (DTI), a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact, on his/her buttocks and ischia (a bone in the lower and back part of the hip bone) and a consultation was provided by the Wound Specialist on 11/4/2025. Record review of a Wound Specialist Note authored by Employee I with a documentation date of 11/4/2025 indicated that an assessment of the wound on Patient ID #9’s sacrococcygeal region (the sacrum and the coccyx, the small, tail-like bone at the very end of the spinal column, region) wound was conducted and documented as follows: “ ...DTI of lower sacrococcygeal region ...[she/he] is seen in consult today for evolving DTI, measuring 10 x 8 cm with superficial opening of 1 x 1 x 0.1 cm at bilateral buttocks, over ischia ...” Further review of the record revealed the wound had progressed from a DTI to a stage IV pressure injury (the deepest PI extending into the muscle, tendon, ligament, cartilage or even bone) at time of discharge and required the use of Negative Pressure Wound Therapy (NPWT, wound vacuum to help promote healing) on 12/2/2025. Review of the medical record for the week of 11/18/2025 and the date of discharge, 12/4/2025, failed to reveal evidence that the stage IV PI on Patient ID #9’s sacrococcygeal region was re-measured weekly and on the day of discharge per the hospital’s policy. During a surveyor interview with the Wound Specialist, Employee I, on 1/27/2026 at approximately 1:45 PM, she revealed that she saw Patient ID #9 weekly but acknowledged that she failed to measure the wounds on the day of discharge and on 11/18/2025. 3. Review of a hospital policy titled, “Skin Care Protocol: Prevention, Treatment, and Use of Pressure Relief devices” last reviewed on 2/1/2024, states in part, “ ...Identify patients at risk by referring to the Braden Scale [an evidence-based assessment tool used widely to predict the risk of developing pressure injuries. It evaluates six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear, assigning a score that reflects the potential risk of skin breakdown with lower scores indicating a higher risk] (see Attachment 1) ...Follow intervention guidelines (ATTACHMENT 2) ...” Review of Skin Protection Interventions for Patient ID #1 failed to reveal evidence that interventions addressing sensory perception, moisture, activity, mobility, nutrition, and friction and shear were implemented in accordance with hospital policy and guidelines for patients identified as high risk (Braden score of 11 or less) or severe risk (Braden score of 9 or less) on the following dates: 11/28/2025 (scores of 9) 12/9/2025 (score of 1) 12/10/2025 (score of 11) 12/11/2025 (scores of 10) 12/28/2025 (score of 9) 12/29/2025 (score of 9) 12/30/2025 (score of 9) Review of Skin Protection Interventions for Patient ID #9 failed to reveal evidence that interventions addressing sensory perception, moisture, activity, mobility, nutrition, and friction and shear were implemented in accordance with hospital policy and guidelines for patients identified as high risk (Braden score of 11 or less) or severe risk (Braden score of 9 or less) on the following dates: 11/29/2025 (scores of 8) 11/30/2025 (scores of 10) 12/1/2025 (score of 11) 12/2/2025 (scores of 11) 12/3/2025 (score of 11) 12/4/2025 (score of 8) During a surveyor interview with the Wound Specialist, Employee I, on 1/27/2026 at approximately 1:45 PM, she acknowledged that the above-mentioned records failed to provide evidence that interventions were put into place according to the hospital’s policy related to patient’s Braden scores. 45769”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 43881 Based on review of hospital documents and staff interviews, the hospital failed to include wound care instructions on the discharge summary for 4 of 6 patients reviewed, Patient ID #s 1, 9, 11, and 12. Additionally, the hospital failed to ensure that follow up appointments and instructions are transcribed accurately upon discharge for 1 of 6 patients reviewed for discharge, Patient ID #3. Findings are as follows: 1. Record review of a hospital policy titled, “Department of Health Continuity of Care Form-Rhode Island” last approved 2/2023, states in part, “...Physician orders/treatments. Please specify number and frequency: List all orders for treatment and care post discharge including the number of times and frequency of each...This would include wound care treatment ...Include all pressure ulcers the patient currently has...Include all other open areas and describe size and appearance...” Record review for Patient ID #1 revealed that while at the hospital, the patient developed a wound on his/her sacrum (the triangular bone at the base of the spine) and a physician order for a wound consultation was provided on 12/18/2025. Record review of a Wound Specialist Note authored by Employee I with a documentation date of 12/18/2025 indicated that an assessment of the wound on the patient’s sacrum was conducted and documented as follows: “Patient noted to have a stage II [damage to the skin that results in the loss of the outermost layer (epidermis) and exposure of the dermis, which is the middle layer of skin. This type of ulcer is presented as a shallow, open wound with a pink or red wound bed] PI [pressure injury] measuring 1 x 0.9 x 0.1 cm [centimeters] of the right side of sacrum. There is no fluctuance erythema or increased temperature please reposition with consideration of pressure injury, and protect with moisture barrier from incontinence...” Review of the Pressure Injury Assessment revealed that on 12/31/2026, Patient ID #1 was documented as having a stage II PI to his/her scrotum. Review of Patient ID #1’s Continuity of Care (CoC) form revealed the Patient was discharged to another facility on 1/8/2026. The CoC form failed to reveal information related to the patient having the above two stage II pressure ulcers including location, treatment, and care post discharge including the number of times and frequency needed for each treatment. Record review for Patient ID #9 revealed while at the hospital, the patient was noted to have a deep tissue injury (DTI, a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact) on his/her buttocks and ischia (a bone in the lower and back part of the hip bone), and a consultation was provided by the Wound Specialist on 11/4/2025. Record review of a Wound Specialist Note authored by Employee I with a documentation date of 11/4/2025 indicated an assessment of the wound on the patient’s sacrococcygeal region (the sacrum and the coccyx, the small, tail-like bone at the very end of the spinal column, region) wound was conducted and documented as follows: “ ...DTI of lower sacrococcygeal region ...[she/he] is seen in consult today for evolving DTI, measuring 10 x 8 cm with superficial opening of 1 x 1 x 0.1 cm at bilateral buttocks, over ischia ...” Further review of the record revealed the wound had progressed from a DTI to a stage IV pressure injury (the deepest PI extending into the muscle, tendon, ligament, cartilage or even bone) at time of discharge and required the use of Negative Pressure Wound Therapy (NPWT, wound vacuum to help promote healing) on 12/2/2025. Review of Patient ID #9’s CoC form revealed that Patient ID #9 was discharged to another facility. The CoC form failed to reveal information related to the treatment, and care post discharge including the number of times and frequency needed for each treatment. Record review of Patient ID #11’s CoC form revealed that the patient was discharged from the hospital. Review of the provider’s note on the discharge summary revealed that she/he has a chronic sacral pressure ulcer that was evaluated, and wound care was consulted. Additionally, the provider note revealed management of the wound included wound care, offloading measures, and skin protection. Further review of the discharge summary and CoC failed to reveal information related to the treatment, and care post discharge including the number of times and frequency needed for each treatment. Record review of Patient ID #12’s CoC form revealed that the patient was discharged from the hospital. Review of the provider’s note on the discharge summary revealed that she/he has a wound to his/her coccyx and right heel and wound care was consulted. Further review of the discharge summary and CoC failed to reveal information related to the patient having a pressure ulcer including, location, treatment, and care post discharge including the number of times and frequency needed for each treatment. During a surveyor interview with the Wound Specialist, Employee I, on 1/27/2026 at approximately 1:45 PM, she acknowledged that the above-mentioned records failed to reveal evidence of wound care instructions related to the pressure ulcers as stated in the hospital policy. 2. Review of a hospital policy titled, “Department of Health Continuity of Care Form-Rhode Island” last approved 2/2023, states in part, “...Continuity of Care Form: Consultation/Referral Form Provide basic essential information when referring a resident/patient for additional assessment...Promoting continuity of care includes sharing thorough and concise patient medical information...” Record review revealed that Patient ID #3 was discharged from the hospital on 1/6/2026 to a skilled nursing facility following a surgical procedure which required a follow up appointment. Review of the discharge CoC form for Patient ID #3 from 1/6/2026 revealed the patient’s postoperative surgical appointment was inaccurately documented as scheduled for 1/1/2025. The patient then returned to the hospital, was readmitted and discharged on 1/15/2026. Upon reviewing the patient’s CoC forms from 1/6/2026 and 1/15/2026, both listed dialysis on Monday, Wednesday, and Friday. During a surveyor interview on 1/21/2026 at 2:50 PM with Case Managers, Employee J and K, they acknowledged that Patient ID #3’s follow-up appointment was dated a year prior to his/her discharge from the hospital and confirmed that that the patient does not attend dialysis. 45769”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 32374 Based on review of hospital documents and staff interviews, it has been determined that the hospital failed to electronically submit a patient’s medication to the correct pharmacy upon discharge, resulting in a delay in the patient receiving their medications for 1 of 1 patient reviewed who was receiving Subutex (medication that minimizes opiate withdrawal symptoms), Patient ID #1. Findings are as follows: A community reported complaint was submitted to the Rhode Island Department of Health on 9/1/2025, identifying that Patient ID #1, who was discharged from a hospital to a skilled nursing facility had to be sent out to an acute care hospital for opiate withdrawal symptoms after the skilled nursing facility was unable to obtain their prescriptions because the hospital sent the discharge prescriptions to the incorrect pharmacy. Review of the patient’s medical record revealed the patient was discharged from the hospital to a skilled nursing facility on 8/30/2025 at approximately 4:00 PM. The patients discharge medications were electronically sent to Omnicare of Rhode Island Pharmacy in error. One of the medications to be filled was Subutex, 8 milligrams, sublingual (under the tongue) to be taken twice daily. During a surveyor interview on 9/4/2025 at 9:00 AM with the hospitals Discharge Planning Nurse, Staff B she confirmed that it is her role to complete the patient’s discharge paperwork, which includes identifying the appropriate pharmacy for the physician to electronically send the patients prescriptions upon their discharge. She stated that the hospital keeps a list to refer to of skilled nursing facilities and their contracted pharmacies. Staff B stated she usually confirms the pharmacy with the skilled nursing facility but did not. On 8/31/2025 Staff B stated she received a call from a nurse at the skilled nursing facility stating that Patient ID #1’s medications were never delivered as expected from the pharmacy. After Staff B reviewed the hospitals discharge information, she noticed that she had entered the wrong pharmacy information for that facility which resulted in the physician sending the prescriptions to the wrong pharmacy. This error resulted in Patient ID #1 not receiving the prescribed medications to prevent opiate withdrawal, resulting in the need to be sent out to an acute care hospital. 45769”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 43881 Based on record review and staff interview, the hospital failed to ensure restraint orders for the management of violent or self-destructive behavior included the required time limits based on age in accordance with federal regulations for 5 of 5 patients reviewed whose records contained restraint orders that did not specify the maximum duration of the restraint, (Patient ID #s 1, 2, 3, 4, and 5). Findings are as follows: 1. Record review revealed that on 5/6/2025, Patient ID #1 was placed in 4-point restraint (used to restrain both arms and both legs) after becoming agitated and combative. The record failed to reveal evidence that the physician’s order for the use of restraints included a time limit in accordance with federal regulations. 2. Record review revealed that on 6/1/2025, Patient ID #2 was placed in 4-point restraints after becoming combative toward staff. The record failed to reveal evidence that the physician’s order for the use of restraints included a time limit in accordance with federal regulations. 3. Record review revealed that on 5/26/2025, Patient ID #3 was physically restrained and subsequently placed in a restraint chair after becoming agitated, assaultive, combative, and unable to be de-escalated. The record failed to reveal evidence that the physician’s order for the use of restraints included a time limit in accordance with federal regulations. 4. Record review revealed that on 4/8/2025, Patient ID #4 was placed in 4-point restraints after becoming combative toward staff. The record failed to reveal evidence that the physician’s order for the use of restraints included a time limit in accordance with federal regulations. 5. Record review revealed that on 6/1/2025, Patient ID #5 was placed in 4-point restraints after becoming agitated, aggressive, verbally threatening and unable to be redirected or verbally de-escalated. The record failed to reveal evidence that the physician’s order for the use of restraints included a time limit in accordance with federal regulations. During a surveyor interview on 6/3/2025 at approximately 3:30 PM with the Risk Manager, she acknowledged that all of the physician orders entered in the medical record for the use of restraints for the above-mentioned patients, did not include a time limit.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(ii) [there must be documentation in the patient’s medical record of the following:] A description of the patient’s behavior and the intervention used. This Standard is not met as evidenced by: 43881 Based on record review and staff interview, the hospital failed to ensure that documentation of restraint use included a complete description of the intervention used as a result of the patient’s behavior as required by federal regulations relative to a physical intervention applied by security personnel during a restraint episode for 1 of 5 patients reviewed who were applied restraints while in the hospital, (Patient ID #1). Findings are as follows: On 5/29/2025, the Rhode Island Department of Health received a complaint in which Patient ID #1 alleged that while being restrained at the hospital, staff held his/her face down and asked him/her if she liked it while using profanity and when she/he spit at them, staff held his/her face down “harder.” Record review for Patient ID #1 revealed she/he arrived at the hospital in May of 2025 with only a sheet covering him/her and no clothes underneath. The record indicated that staff attempted to dress the patient in a hospital gown, but the patient became agitated. When staff attempted to transfer the patient from a stretcher onto a hospital bed, the patient became combative and 4-point restraints (used to restrain both arms and both legs) were applied. Record review of nursing progress notes dated 5/6/2025 authored by Employee A, Licensed Practical Nurse (LPN), indicated that after 4-point restraints were applied on the patient, the patient was able to remove both wrist restraints. When staff attempted to reapply the restraints, the patient attempted to swing and grab staff, and then spit on a security guard and a code gray was initiated. During a surveyor interview on 6/3/2025 at 9:20 AM with Employee B, Lead Security Officer, he stated that the patient had “slipped out” of both wrist restraints and so he entered the patient’s room, “grabbed” the patient’s hands, “controlled” the patient’s arms, and the patient then spit on his left cheek. He explained that he was able to control one of the patient’s arms while the nurse controlled the other arm and at that time, he applied a “safety hold” on the patient by placing the palm of his right gloved hand on the patient’s jawline for approximately 30 seconds, turning the patient’s face away from him to prevent the patient from spitting at him, until other staff arrived to help restrain the patient. Further review of nursing progress notes and restraint documentation failed to reveal evidence describing the physical intervention used by Employee B to prevent the patient from spitting at him. During a surveyor interview on 6/3/2025 at approximately 9:30 AM with Employee A, LPN, she was unable to explain why Employee B’s physical intervention was not documented in the medical record. During a surveyor interview on 6/3/2025 at approximately 3:15 PM with Employee C, Educator, he indicated that he would hope there would be documentation in the medical record reflective of the restraints applied to the patient during a restraint episode.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 32374 Roger Williams Hospital (RWH) failed to ensure compliance with the Emergency Medical Treatment and Labor Act requirements related to the following: 1. Failure to maintain a central log (a log maintained by the hospital on each individual who comes to the Dedicated Emergency Department; ED) for a patient who presented to the ED with complaints of vaginal bleeding and abdominal pain, following a medical procedure (A-2405). 2. Failure to ensure that a comprehensive medical screening examination (MSE) was performed on a patient who presented to the Emergency Department (ED) with complaints of vaginal bleeding and abdominal pain, following a medical procedure (A-2406). 3. Failure to ensure a patient was stable for transport, and the receiving facility was notified in writing of the patient’s medical condition and the need for continued care (A-2409).”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 32374 Based on record review and staff interview, it has been determined that the hospital failed to maintain a central log (a log maintained by the hospital on each individual who comes to the Dedicated Emergency Department; ED) for a patient who presented to the ED with complaints of vaginal bleeding and abdominal pain, following a medical procedure, for 1 of 25 patients reviewed who presented to the hospital’s ED for treatment, (Patient ID #1). Findings are as follows: Record review of the hospital’s Emergency Department Daily Log was completed on 3/19/2025. The Daily Log contained documentation of all patients who entered the Emergency Department from September 2024 to March 17, 2025. Patient ID #1 did not appear in the log on 3/14/2025. During a surveyor interview with the Employee K and Employee G on 3/19/2025 at 10:30 AM, they acknowledged that Patient ID #1 presented to RWH ED on 3/14/2025 and was not registered into the ED Daily Log Sheet as required. Additionally, Employee K acknowledged that the Hospital’s Electronic Medical Record failed to contain evidence that the patient had presented to the hospital’s Emergency Department on 3/14/2025.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 32374 Based on record review and staff interviews, it has been determined that the hospital failed to ensure that a comprehensive medical screening examination (MSE) was performed on a patient who presented to the Emergency Department (ED) with complaints of vaginal bleeding and abdominal pain, following a medical procedure, for 1 of 20 patients reviewed who presented to the hospital’s Emergency Department for treatment. (Patient ID #1). Findings are as follows: A review of the EMS Patient Care Report sheet dated 3/14/2025 revealed the following information: Dispatch Date and Time: 3/14/2025, 03:32 AM Arrival to Destination: 3/14/2025, 3:56 AM, at RWH Depart time: 3/14/2025, 4:07 AM; from RWH Arrival at Destination: 3/14/2025, 4:25 AM; to Hospital B During a surveyor interview with Staff B, on 3/19/2025 at 3:00 PM in the presence of the Staff K and the Staff F, she revealed that she was on duty at RWH on the night of 3/14/2025. Staff B indicated that she remembered being called out of a patient room and was informed by Staff A, that Patient ID #1 was brought in for abdominal pain and vaginal bleeding. Additionally, she was informed by Staff A that the patient had previously underwent a procedure at Hospital B and so Staff B thought that the patient should go back to that hospital because RWH does not provide those services during the night. Staff B then stated that the patient was “stable” and she determined this by “eyeballing” the patient, indicating that she did not conduct an examination of the patient. Furthermore, Staff B acknowledged that she did not call Hospital B to inform them that the patient was enroute to them and was unaware if EMS had done so, stating “how would I know that.” During a surveyor interview with the Staff F on 3/19/2025 at 3:30 PM he explained that he would have expected that the patient would have been registered as an ED patient, triaged, and evaluated by the ED physician. He indicated that a medical screening exam should have been performed, and then the patient should have been transferred to Hospital B if needed. Staff B acknowledged that the attending physician failed to follow the hospital’s EMTALA policy and conduct a comprehensive medical screening examination on Patient ID #1 prior to his/her transfer to another acute care hospital. During a surveyor interview with Staff C, on 3/20/2025 at 7:30 AM, she explained that she was not at the charge desk when Patient ID #1 arrived in the ED. She revealed that she observed EMS and Staff A speaking with Staff B. She indicated that EMS wanted to take Patient ID #1 to Hospital B based on his/her complaints, but the patient insisted on going to RWH. It was then determined that EMS would then take the patient to Hospital B, and they left. Staff C stated that she “was shocked” that Staff B would just let EMS take the patient and acknowledged that the hospital’s registration and triage policy was not followed. During a surveyor interview on 3/20/2025 at 11:05 AM with Staff A, she stated that on the night of 3/14/2025, the rescue stopped at her desk and so she told them that she would receive the patient. She indicated that EMS believed that the patient had a previous surgical procedure at the RWH, however, upon reviewing the patient’s discharge paperwork from two nights prior, she realized that the patient was seen in RWH ED previously for abdominal pain and bleeding, and was advised at that time, to return to Hospital B or the outpatient facility where the medical procedure had been performed. Staff A indicated that she usually reviews any paperwork provided by EMS, and then decides if the patient needs to be roomed or go to the express area or go to the waiting room. Staff A stated that the doctor, Staff B then came over and asked the patient if they had their Procedure at Hospital B, and the patient nodded his/her head “yes” while still on the stretcher, and she asked the doctor if she wanted EMS to bring the patient to Hospital B. Staff A was unable to explain why she deviated from the normal triage process by not registering the patient. Staff A acknowledged that she did not follow the proper protocol for this patient and then stated that the patient was on hospital grounds, inside of the hospital, but was “still on the ambulance stretcher” when the decision to divert the patient to Hospital B was made.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 32374 Based on record review and staff interview, it has been determined that the hospital failed to ensure a patient was stable for transport, the receiving facility was notified in writing of the patient’s medical condition and the need for continued care, for 1 of 25 patients reviewed who presented to Roger Williams Hospital (RWH) Emergency Department for treatment. As a result, the patient was transferred to another acute care hospital without a Medical Screening Examination in accordance with federal regulations, which had the potential to jeopardize the patient’s health and well-being, (Patient ID #1). Findings are as follows: During a surveyor interview with Staff B on 3/19/2025 at 3:00 PM, in the presence of the Staff K and Staff B, she revealed that she was on duty at RWH the night of 3/14/2025. Staff B indicated that she remembered being called out of a patient room and was informed by Staff A, that Patient ID #1 was brought in for increased abdominal pain and vaginal bleeding. Additionally, she was informed by Staff A that the patient had previously underwent a medical procedure at Hospital B and thought that the patient should go back to that hospital because RWH does not provide those services during the night. Staff B then stated that the patient was “stable” which she had determined by “eyeballing” the patient, indicating that she did not examine the patient. Furthermore, Staff B, acknowledged that she did not call Hospital B to inform them that the patient was enroute to them and was unaware if EMS had done so, stating “how would I know that.” During a surveyor interview with Staff F on 3/19/2025 at 3:30 PM, he revealed that he would have expected that the Patient ID #1 would have been registered as an ED patient, triaged, and evaluated by the ED physician when s/he arrived at the hospital’s emergency department. Additionally, he revealed that a medical screening examination should have been performed prior to the patient’s transfer to ACH-B. He acknowledged that RWH failed to document Patient ID #1’s arrival in RWH emergency room.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 32374 Based on record review and staff interview it has been determined that the hospital failed to reassess the patients discharge needs and notify the patients guardian of a change in the discharge plan for 1 of 1 Patient with a court appointed guardian, Patient ID #1. Findings are as follows: Review of the record for patient ID #1, reveals that s/he was brought to the hospital emergency department (ED), on 1/18/2025 at approximately 10:30 AM, by ambulance from the skilled nursing facility (SNF) for a psychiatric assessment. While at the SNF the patient allegedly attempted to physically assault staff, making racial slurs and verbally aggressive. Records indicate a history which includes anxiety, depression, and a chronic alcohol problem. The Record also indicates the patient has had similar behaviors while in the ED in the past. While in the ED, the patient denied exhibiting the behaviors alleged. The patient was noted to be demanding, and ordered the staff the s/he be returned to the SNF. The patient denied any physical complaints during this visit. Review of the Physicians note reveals he spoke with the facility, and they refused to take the patient back due to a concern for their employees’ safety. The record noted that the patient’s guardian stated he spoke with the facility, and they agreed to take the patient back. A nursing note indicated the nurse spoke with the facility, and they could not take the patient back right away. The patient was seen by the hospitals Social Worker on 10/18/2025 at 10:45 AM. This note indicated a discharge plan for the patient to return to the SNF with medication management. The note also stated she interviewed the patient’s guardian and informed him of the plan for the patient to return to the SNF on Monday to which the Guardian agreed. The nurses note states nursing spoke to the DON at the nursing home, who reported they did not have a room to accommodate the patient’s return on the weekend but would have a meeting on Monday to explore this possibility. The patient was aware of this conversation and requested to call his guardian. The patient called his guardian, and he is aware that the patient will be spending the weekend in the ED. The Primary nurse was aware of the plan. Notes indicated that the next morning at 8:15 AM when given breakfast the patient became verbally aggressive with staff telling them to F .... Off. This behavior continued until at approximately 12:10 PM the patient attempted to leave the ED to go out to smoke a cigarette. The patient was noted to be verbally aggressive and pushed the staff with his/her walker. The patient was found attempting to leave via the ambulance entrance and was redirected back to bed with security present. The patient refused to remain in the ED and requested to sign out AMA (against medical advice). The Patient was allowed to sign the AMA form with the physician, then walked out of the ED and waited for a friend to pick him/her up. During an interview with the Social Worker and Director of Case Management on 1/22/2025, both were unaware that the patient had signed out against medical advice. During an interview with the Emergency Department Nurse Manager on 1/22/2025 at approximately 1:00 PM, she informed the surveyor that this patient is well known to the ED staff, and they were unaware that the patient had a court appointed guardian. During an interview with the hospitals the Risk Manager on 1/22/2025 at approximately 11:00 AM, she was unable to explain why the patient’s legal guardian was not contacted prior the the patients release. The hospital failed to contact the patient’s legal guardian when the patient refused to remain in the ED.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 30526 Based on surveyor observation, record review and staff interview it has been determined that the hospital failed to ensure the safety of all patients, staff, and visitors in accordance with 42 CFR 482.41 Conditions of Participation: Physical Environment related to multiple areas throughout the hospital noted to have water leaking in from the roof. Additionally, it was determined that the facility failed to maintain a safe environment by maintaining compliance with the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC). Please refer to the FORM CMS-2567 Life Safety Code report. 1. During the survey a finding which constituted an Immediate Jeopardy (IJ) was identified relative to a surveyor observation on 3/29/2024 at approximately 1:15 PM of the hospital laboratory that revealed water leaking from the ceiling into a 2’ x 4’ recessed florescent light fixture which was connected to power. Additionally, multiple wet ceiling tiles were observed surrounding the light fixture, and water was running down the sides a concrete column. Further observation of the laboratory revealed additional areas where water was leaking. A floor covering with a waste basket placed on top of it was collecting the leaking water. Additionally, observation of a window in the endoscopy (patient care area) revealed a sopping wet blanket on the windowsill, which was placed there to absorb the rainwater that was leaking in from the window. The hospital Risk Manager and Maintenance Director were informed of the Immediate Jeopardy that was identified on 3/29/2024. The Hospital Risk Manager was provided with the Immediate Jeopardy template on 3/29/2024 at approximately 2:15 PM. 2. During an environmental tour of the hospital, the corridor in the operating room was noted to have two large, covered barrels with hoses running up into the drop ceiling. This hose was connected to leak diverters within the ceiling. These covered barrels were collecting the water that was leaking into the hospital from the roof. Similar barrels with hoses were observed on the Center 4 patient care unit, Center 3 patient care unit, the hallway leading to the laboratory, and in the back of the cafeteria. Additionally, a large pool of water was observed to have accumulated from rainwater leaking into the hospital through a wall observed in the first-floor hallway outside of the Women’s Rest Room, near the conference room. (Refer to A-0701)”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 30526 Based on surveyor observation, record review and staff interview, it has been determined that the hospital failed to ensure that the physical condition of the hospital was maintained in a manner to ensure the safety and well-being of the patients, staff, and visitors. Findings are as follows: During a tour of the hospital on 3/29/2024, surveyor observations revealed rainwater infiltrating several areas in the hospital from multiple roof leaks. The Affected areas included the Operating Suite, Laboratory, Center 4 Patient Unit, Center 3 Patient Unit, Cafeteria, Ladies Room first floor near the conference room, ground floor corridor leading to the laboratory and the endoscopy suite. Additionally, there were two other areas in the core lab where the rainwater was entering the lab from the ceiling. Absorbent pads were observed on the floor, as well as waste baskets to collect the rain water were positioned under the areas with leaks. Water damage was observed on the walls, windows, windowsills, and ceiling tiles during the tour. Life Safety Code Citations were identified in conjunction with this survey. 1. During tour of the hospital laboratory located on the ground floor in the diagnostic wing, cytology section, with the Risk Manager and the Maintenance Director on 3/29/2024 at approximately 1:15 PM, the surveyors observed an area of the ceiling where a 2’ x 4’ recessed florescent ceiling light was noted to have water in the fixture, which was connected to power. Additionally, there were multiple wet ceiling tiles surrounding the light and water running down the sides the concrete column adjacent to it. At approximately 1:30 PM on 3/29/2024, the Manager of the Lab, was interviewed by the surveyors. He stated that there are multiple areas in the lab where they have ongoing issues with leaks when it rains. He informed the surveyors that the maintenance department was made aware of the leaks in January, and work orders had been submitted relative to leaks in the cytology section of the lab. Additionally, he stated that he had spoken with the Maintenance Manager who was also aware of the leak and had informed him that someone from the roofing company would be in next week. He informed the surveyors that the water leaks throughout the hospital have been an ongoing issue when it rains. A Review of the work requests provided to the surveyor revealed multiple work order requests requesting repair of the roof due to leaking rainwater revealed work orders for areas throughout the hospital since January 2024. During surveyor interview with the Director of Maintenance at the time of the observation, he stated that he was unaware of the leak in the cytology area of the lab. Although the Director of Maintenance informed the surveyors that he was unaware of the leaking roof in the cytology area of the lab, review of a work request provided to the surveyors revealed a work order (WO) request had been submitted to the maintenance department relative to the concrete column and ceiling leak in the cytology area of the lab dating back to 1/11/2024. The above finding of the water in the recessed light fixture in the cytology area of the lab, constituted an Immediate Jeopardy (IJ). The hospital Risk Manager, and Maintenance Director were informed of the Immediate Jeopardy identified on 3/29/2024. The Hospital Risk Manager was provided with the Immediate Jeopardy template on 3/29/2024 at approximately 2:15 PM. During the surveyors return to the laboratory with the Director of maintenance on 3/29/24 at approximately 3:30 PM to verify the immediate corrective action had been implemented related to the light fixture containing water in the cytology area of the lab, another barrel with a hose connecting it to the ceiling was observed in the hallway leading into the lab. When questioned about how long this barrel and diverter system had been in place, he stated that he was unaware of the barrel in this area. He stated the barrels are placed to catch the rainwater when a leak is identified. 2. During a tour of the operating room (OR) with the operating room Nurse Manager and the Risk Manager on 3/28/2024 at approximately 11:15 AM, relative to a complaint, the following was observed: The main area (corridor) in the OR, where the scrub sinks are located, and 8 OR suites are located, as well as supply rooms, was noted to have two large, covered barrels with garden hoses observed to be running up into the dropped ceiling and connected to leak diverters in the ceiling to contain the rainwater. Barrels were observed to have a cover with a hole cut in the center of the cover where the garden hose was placed to drain the water. During surveyor interview with the OR Nurse Manager, at the time of the observation, she informed the surveyor that the barrels have been in the OR since she started to work at the hospital in July of 2023. She stated that the maintenance department takes care of emptying the barrels when needed. During a tour of the OR, an interview was conducted with the Infection Control Nurse regarding the barrels present in the OR suite. He stated that he was aware of the barrels and did not have any infection control concerns relative to the barrels being present there. He stated that the roof needs to be repaired or replaced, and the hospital is diverting the rainwater by the use of a roof diverter funneling the water into the barrels. During surveyor interview with the Maintenance Director who came to the OR during the tour on 3/28/2024, he stated that these leak diverters are an approved system and used in many buildings to collect water from leaks. A Review of the 9/6/2023 Operating Room Committee Minutes, revealed; “Discussion Physician Issues: Barrels in the operating room hallways that collect water leaks are an ongoing issue”. The Outcome/Action Plan states “This was explained we need a new roof”. 3. During the surveyor tour of the hospital on 3/29/2024, which included a CMS certified Life Safety Surveyor, Director of Maintenance, and the Risk Manager the following issues were observed: -The Center 4 Patient Unit, in the hallway in front of the nurse’s station, a leak diverter system was observed in the ceiling with 4 plastic covered buckets with white hoses connected from the ceiling down into the buckets to collect the rainwater. -On the Center 3 patient unit, in the hallway in front of the nurse’s station was observed to have a leak diverter system in the ceiling and a plastic covered buckets with a hose connected from the ceiling down into the bucket to collect the rainwater. -On the Endoscopy suite, a window was observed in a patient care area, where water was leaking in through a window and staff had placed a blanket on the windowsill to contain the water which was noted to be saturated with rainwater. -The cafeteria revealed a large barrel with a garden hose connected to the ceiling leak diverter, which was brought to the attention of the Risk Manager and the Director of Maintenance, who were unaware of the water leak. -A large ponding of water was noted in the first-floor hallway outside of the Ladies Room, near the conference room, due to rainwater leaking into the building through the wall. This area had caution wet floor signs around the large area of water. On 4/2/2024, at approximately 11:10 AM, the surveyors accompanied by the Director of Maintenance observed the wall in the lady’s room/locker area. The wall was noted have several holes from water damage, as well as water damage along the length of the wall. Blankets were in place on the floor against the wall to collect the leaking water. During a surveyor interview with Director of Maintenance and the Manager of Maintenance on 4/2/2024, the Director informed the surveyors that “everyone is aware of the issues with the water leaks from the rain” he stated he is on the Safety Committee and has reported the issues with the water leaks and that the hospital has the roof repairs in the Capital Budget. A Review of the Safety committee minutes from March 2023 through February 2024 revealed no documentation of the water leaks. The above findings constitute condition level deficient practice.”