Our Lady of Fatima Hospital

“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: 46539 Based on clinical record review and staff interviews, the hospital failed to ensure that all necessary medical information relating to a patient’s current course of illness, treatment, condition, and post-discharge care needs was provided to the receiving facility at the time of transfer for 1 of 1 sampled patient (Patient ID #1) who sustained a fall while receiving care in the Emergency Department (ED). Findings are as follows: A complaint received by the Rhode Island Department of Health on 5/20/2026 alleged that a patient transferred from a skilled nursing facility (SNF) to the hospital for evaluation following a fall sustained an additional fall while in the ED and was subsequently returned to the SNF without updated discharge documentation regarding the in-hospital fall, treatment provided, diagnostic testing results, or follow-up care instructions. Review of Patient ID #1’s medical record revealed the patient was transferred from a SNF to the ED in May 2026 following an unwitnessed fall and complaints of hip rotation. Review of the ED Nursing Progress Note dated 5/17/2026 at 2:40 PM documented that staff heard a loud bang and found Patient ID #1 unconscious on the floor beside the stretcher. Further record review revealed that following the fall, the patient was assessed and found to have sustained a transverse occipital laceration measuring approximately 1.5 inches. A post-fall CT scan of the head was performed and interpreted as negative for acute injury. The laceration was cleansed and closed with seven (7) staples. The patient was subsequently discharged and transferred back to the SNF. Review of the discharge records and Emergency Room Visit Notes transmitted to the receiving SNF failed to include documentation regarding the in-hospital fall, post-fall assessments, CT scan results, staple placement, or instructions for post-fall monitoring and follow-up care. Comparison of the documents provided to the SNF with the complete ED record revealed the discharge paperwork had been printed prior to the in-hospital fall and was not updated before the patient’s transfer to the SNF. During an interview on 6/1/2026 at 11:27 AM, the Director of the Emergency Department stated that information regarding the in-hospital fall was communicated verbally to the SNF during nurse-to-nurse report. However, she was unable to provide evidence that written documentation regarding the fall, post-fall assessment findings, diagnostic testing, treatment provided, or follow-up care instructions accompanied the patient at the time of transfer. The Director further stated that the hospital received a telephone call from the SNF the day following discharge indicating the facility had not received documentation regarding the patient’s in-hospital fall. She stated the requested records were subsequently faxed to the SNF after the receiving facility contacted the hospital. The findings demonstrated the hospital failed to ensure that complete and accurate medical information regarding the patient’s condition, treatment, and follow-up care needs accompanied the patient at the time of transfer to the receiving facility.”

“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 ensure the medical staff was accountable for providing care in accordance with mandatory hospital processes. Specifically, 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). Specifically, for Patient ID #1 and Patient ID #2, ED physicians documented in the clinical record that their interpretation of the X-ray showed no fracture. However, the final official radiology reports identified fractures for both patients. 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 platform as required. As a result, the fractures were not communicated to the ED physicians, the patients, or, for Patient ID #1, the staff at the patient’s Assisted Living Facility following discharge.(A-0347).”

“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 4 of 4 patients reviewed. Specifically, for Patient ID #1 and Patient ID #2, ED physicians documented in the clinical record that their interpretation of the X-ray showed no fracture. However, the final official radiology reports identified fractures for both patients. 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 platform as required. As a result, the fractures were not communicated to the ED physicians, the patients, or, for Patient ID #1, the staff at the patient’s Assisted Living Facility following discharge. Findings are as follows: 1. Clinical record review revealed that Patient ID #1 presented to the Emergency Department in December of 2025 complaining of left hip pain following a fall at his/her Assisted Living Facility. While in the Emergency Department, the patient complained of pain to his/her other hip and a result, X-ray imaging was obtained for the left and right hips. The Emergency Department Physician who evaluated the patient indicated in the patient’s clinical record that X-ray imaging did not show “obvious fractures or dislocation.” The patient was then discharged back to his/her Assisted Living Facility with a diagnosis of neurocognitive disorder and a contusion of the hip. Further review of the patient’s clinical record revealed that the Radiologist performed an official final read of the patient’s X-ray results confirming that the patient had a fracture in the front part of the left hip bone that shifted slightly out of place. The record failed to reveal evidence that the new information was communicated to the patient or the staff at the patient’s Assisted Living Facility. 2. Clinical record review revealed that Patient ID #2 presented to the Emergency Department in September of 2025 for a mental health evaluation. While in the Emergency Department, the patient complained of pain to his/her ankle from a recent injury and as a result, X-ray imaging was obtained for the left ankle. The Emergency Department Physician who evaluated the x-ray indicated in the patient’s clinical record “no fracture seen.” Further review of the patient’s clinical record revealed that the Radiologist performed an official final read of the patient’s X-ray results confirming that the patient had a nondisplaced fracture of the distal tibia. During a surveyor interview with the Medical Director of the ED on 1/7/2026 at 11:30 AM he acknowledged that the ED physicians had not put their preliminary reads into the Rhode Island Medical Imaging (RIMI) system 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.”

“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: 45769 Based on record review, video tape observation, and staff interviews, the hospital failed to ensure nursing personnel followed hospital protocol relative to a behavioral health patient who was allowed to leave the unit without confirming their identity, which resulted in the patient eloping from the hospital through the front door, Patient ID # 1. Findings are as follows: A facility report was submitted to the Rhode Island Department of Health on 12/17/2025 indicating that Patient ID #1 was found to be missing from the behavioral health unit on 12/16/2025. During the search it was discovered that Employee A had mistaken the patient for a visitor and let them out of the unit. Medical record review revealed the patient was admitted to the hospital’s behavioral health unit, in December of 2025 on an involuntary status due to erratic behavior and disorganized thoughts. The physician’s orders indicated that the patient was placed on fifteen minute safety checks. Review of the video tape footage of the behavioral health unit hallway on 12/16/2025 revealed Employee A exiting the staff room, and Patient ID #1 is seen standing at the exit door of the unit at approximately 1:49 PM. The patient is seen touching the door handle and looking out the window of the door. The patient was wearing a zipped up sweatshirt. Employee A is seen approaching the patient, standing on his/her left side and then is seen unlocking the door. The patient walks out of the unit at approximately 1:50 PM. After opening the door to the unit the employee then turns around without making sure that the door was securely closed and walks back toward the nurse’s station. Review of the video tape at approximately 2:05 PM shows Patient ID #1 walking out of the front door of the hospital. During a surveyor interview with the Human Resource Representative, Employee B, she explained that she was present for the hospital’s interview with Employee A. Employee A stated that she was returning from her break, and she noticed Patient ID #1 standing at the door. She said that she believed that he/she was a visitor, and asked “Are you a visitor and then asked is your visit over”, stating that the patient responded yes to both questions. Employee B documented that Employee A, thought she noticed that the patient had a visitor badge on. Employee B then confirmed that the video did not contain evidence that the patient was wearing a visitor badge. During a surveyor interview with Staff Nurse C and D, on 1/8/2026 at 9:30 AM, they explained that visitation on the unit requires an appointment. The unit secretary has a visitation schedule posted in the nursing station. Visitation hours are normally from 1:00 PM to 3:00 PM on the day shift. The staff stated that all visitors are escorted to the unit by security after they have been screened. They both stated that there are multiple ways to identify a patient on the unit which include checking of the patient’s armband, the unit book with photograph identification, and verification from the patient of their name and date of birth. During an interview with the Nursing Director of Behavioral Health on 1/8/2026 at 2:00 PM, she acknowledged that Staff Nurse A did not follow the hospital’s process for verifying the identity Patient ID #1 prior to opening the door which resulted in Patient ID #1 eloping from the hospital.”

“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: 32374 During a Federal survey conducted 9/25/2025 through 9/29/2025, it was identified that the hospital failed to maintain a safe environment in the dental suite of the operating room (OR), related to a chemical spill involving Forma-cresol (a mixture consisting of formalin, cresol and glycerin used in dentistry) which occurred at approximately 2:30 PM on 9/22/2025. The hospital failed to follow the hospital’s hazardous material cleanup protocol resulting in a hazardous chemical which was not promptly and appropriately cleaned creating a potentially hazardous environment to staff and patients. (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: 32374 Based on record review and staff interviews it has been determined that the hospital failed to ensure that the physical environment is maintained in a manner that promotes safety and minimizes health hazards related to a chemical spill in the dental operating room (OR). Findings are as follows: Review of a Safety Data Sheet (a standardized document that provides essential information about a chemical substance or mixture) for the product Forma-Cresol, states in part; “Hazardous ingredients: Cresol (<50%), Formaldehyde (<50%), Glycerin (<5%)”. Personal Precautions: avoid contact with skin or eyes ...Environmental Precautions; dispose of in accordance with all federal, state and local regulations ...Methods for cleaning up; use foam to control vapors, flush area with water sparingly or use absorbents to contain and or remove spill.” Review of the hospital ‘s policy titled “Code Orange Hazardous Materials Release, states in part; Policy; ... “Appropriate equipment for the safe use of the chemical; as well as for clean-up of incidental spills are to be maintained in the department or in an easily accessible nearby location. General spill kits are located in most areas of the hospital.” Small manageable spills of known chemicals will be contained and cleaned up in the department or area responsible according to the recommendations found on the label and or SDS” ... II. Equipment: “all nursing units and departments that use chemicals regularly in their everyday routine are supplied with a General Spill Kit on and exchange program from Central Services.” The hospitals failure to promptly and appropriately clean the chemical spill created a hazardous environment, violating safety standards that resulted in chemical fumes in the dental OR and surrounding areas of the OR. It also demonstrated noncompliance with the hospital’s own environmental safety policies. During an interview with the Risk Manager on 9/25/2025 at approximately 9:15 AM, relative to the reported chemical spill in the dental OR on 9/22/2025, She informed the surveyor that the OR staff called for “room turnover” following a procedure and that the “Nurse Extenders” (cleaning staff) had gone to the dental OR to clean the room. Staff D, E and F were on duty for cleaning and responded to the call. During an interview with Staff D, on 9/25/2025 at 1:00 PM, he informed the surveyor that he was in the dental OR to help with the cleaning, when the Dental Assistant, Staff G, told him there was a spill on the floor that needed to be wiped up. He stated that he observed Staff G wiping up the spill. He stated it appeared to be a clear liquid which he thought was water. He stated he did not see broken glass on the floor. Staff D stated he would have notified the manager if he was informed it was a chemical spill. During an interview with Staff E, at approximately 1:15 PM, he stated that he was in the OR room cleaning, and the dental staff were cleaning up from the procedure which was just completed. He stated he heard Staff D, call for Staff F to come in with a mop. Staff E stated he was unaware the liquid spill was a chemical. During an interview with Staff F, at approximately 1:30 PM, he stated that he came to the dental OR with the mop to clean the spill as directed. He stated that he sprayed the floor with disinfectant cleaner which they normally use on the floors and mopped up the spill unaware that the spill was a chemical substance. During an interview with the Operating Room Nurse Manager, Staff A on 9/26/2025 at approximately 10:35 AM, she stated that the Dental Assistant, Staff G, dropped a bottle of Form-Cresol causing a chemical spill at approximately 2:30 PM when she was cleaning up after the dental procedure. She stated that from her office which is located across the hall from the Dental OR, she heard staff saying, “what is that smell” and exited her office. She said that she could smell something “rotten/ pungent”. Staff A stated she opened the door to the Dental OR, noted the odor, returned to her office and called the Code Orange (hazardous material spill). She instructed staff to move the patients in the nearby Post-Anesthesia Care Unit (PACU) away from the area. Staff A stated that Staff C, the Environmental/Security Officer arrived and called the Fire department.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 45769 Based on observation, employee interviews, and record reviews, it has been determined that the hospital failed to prevent abuse for 1 of 1 patient (ID #1) who was abused by staff. The hospital failed to ensure that staff who had knowledge of, or reasonable cause to believe that a patient had been abused, notified Risk Management immediately in accordance with the hospital’s policy for 1 of 1 patient who was abused, (Patient ID #1). Additionally, the hospital failed to ensure all employees were provided ongoing education regarding abuse, neglect and reporting requirements. Findings are as follows: The hospital’s policy titled, “Mandatory Reporting of Patient Abuse & Patient-To-Patient Abuse” last revised in July of 2022 states in part: “ ...Abuse ...intentionally engaging in a pattern of harassing conduct which causes or is likely to cause emotional or psychological harm to the patient or resident, including but not limited to ...cursing directed towards a patient or resident ... Procedure ... ...Any healthcare worker who has knowledge of or reasonable cause to believe that a patient has been abused ...shall notify the Risk Management Department immediately ...” On 6/4/2025, Our Lady of Fatima Hospital submitted a report to the Department of Health alleging Employee A was observed with his hands on Patients neck holding he/she down onto the stretcher. A review of Patient ID #1 ‘s electronic medical record revealed the patient presented to the Emergency Room (ED) on 6/2/2025 with wounds to both hands. The patient acknowledged that s/he had been drinking alcohol prior to arrival. Employee A, provided the hospital with a written statement regarding the events that occurred on 6-2-2025. He documented that he was preparing to place an intravenous line in Patient ID #1, when s/he became combative, grabbing Employee A’s hand and attempting to push the needle into him. He stated that he immediately yelled for security to be called. He then wrote that the patient reached across him, and attempted to get up and grab the scissors from his pocket. Employee A documented that “in a defensive manner I pushed him back with the palm of his hand”. He indicated that multiple staff responded, and 2 nurses and a Security Guard. During a surveyor interview on 6-16-2025 at 3:00 PM with Employee B, he stated that he responded to the patient’s room after he heard someone call for security. Upon his entering the room he stated that security was already there near the patient’s feet. He revealed that he went up to the head of the bed to assist Employee A, he witnessed Employee A aggressively push Patient ID #1 back down. He stated Employee A had his hands at the base of the patient’s neck. He then explained that he took over and easily deescalated the situation and the event was over very quickly. After the event he confirmed that he reported his concerns to Employee C. Employee B confirmed that at no time did he see the patient with scissors in his/her hands, nor did he see the patient hit Employee A. During a surveyor interview on 6-16-2025 at 3:45 PM with Employee D, she revealed that she was sitting at her desk which was directly in front of Patient ID #1’s room. Approximately 2 PM, she heard Employee A call out to “call security”. She stated that she stood up and looked into the room and saw Employee A with his hands around Patient ID #1” s neck pushing him/her down onto the stretcher. She stated that she heard Patient ID #1 crying saying that she/he was not trying to give anyone a hard time, Employee D also stated that she did not see the patient with scissors in his/her hand. She confirmed that the curtain to the room was open, and she could see clearly into the patient’s room. She stated that she reported what she saw to Employee C. During a surveyor interview with the Employee G, on 6-16-2025 at 4:15 PM she stated that she became aware of the event after it was entered into the system the next day. Employee A was contacted on 6/3/2025 by the Nursing Director and was instructed not to report to the hospital for his next shift, and his contract was terminated. During a surveyor interview on 6-17-2025 at 10:00 AM, with Employee D, she stated that she was the charge nurse on that day, however, she was not in the patient’s room during the incident. She stated that both Employee B and Employee D had spoken to her after the incident and reported that Employee A, had aggressively put his hands on Patient ID #1’s neck. She stated the next day she entered the incident into the hospital’s electronic reporting system. During a surveyor interview on 6-17-2025 at 12:50 PM with Employee E, he stated that he was assigned to the ED on the day of the incident, he entered the room of Patient ID #1, and saw the patient grabbing at Staff A. He reported he reached for the patient’s arms and he was instructed by the nurses to be careful of the patient’s hand which was injured, so he held him down by placing one hand on the patient’s shoulder and another on his forearm. He stated that the patient easily calmed down and was cooperative. During a surveyor interview on 6/16/2025 at 11: 00 AM with Staff F, she failed to provide evidence that all ED employees had received ongoing training regarding abuse, and neglect, including reporting requirements. During an interview with Staff G on 6/17/2025 at approximately 1:00 PM, she confirmed that the hospital’s current annual credentialing does not include ongoing training for abuse, neglect, and reporting requirements.”

“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: 45769 Based on review of medical records, hospital documents, and staff interviews, it was determined that the hospital failed to ensure that nursing personnel adhered to hospital policies related to the completion of a Central Line Checklist for 1 of 5 patients reviewed who had a central line placed during their hospital admission. (Patient ID #2). Findings are as follows: The hospital’s “Central Line Insertion Reminder” which is attached to all central line insertion kits, states the following: “1. The two person insertion checklist must be completed for every central line insertion ... ...4. The completed checklist will be scanned into the medical record.” Review of Patient ID #2’s medical record revealed that a right and left femoral line was inserted while in the emergency room on 6/8/2025 by Staff H. The record failed to reveal evidence that the central line insertion check sheet was completed and scanned into the patient’s record as per the hospital policy. During a surveyor interview with the Employee G on 6/19/2025, she acknowledged that Patient ID #2’s medical record contained no central line check sheet for the right or left femoral lines that were placed on 6/8/2025.”

“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: 45769 Based on record review and staff interview it has been determined that the hospital failed to adhere to their policy, to ensure that the Continuity of Care form, included instructions and information regarding the patient’s wound measurements and ongoing dressings/treatments for 1 of 4 patients reviewed, Patient ID #1. Findings are as follows: Review of the hospital policy titled “Skin Care Protocol: Prevention, Treatment and Use of Pressure Relief Devices” Revised 3/2023 states in part: Documentation: ...6. Include documentation of wound care on the Continuity of Care Form along with wound measurement, treatment and teaching/supplies/equipment needed for discharge. Review of Patient ID #1’s medical record revealed a 47 year old, with a known history of chronic schizophrenia, and homelessness, who was emergency certified due to symptoms of delusional thinking and self-neglect resulting in a severe wound infection. The patient was transferred and admitted to Our Lady of Fatima’s behavioral health unit on 5/6/2025 for ongoing treatment. Upon the patients discharge on 5/14/2025, a Continuity of Care Form was given to the patient indicating that the patient needed to attend continued follow up appointments for wound care at the hospital’s outpatient wound clinic. An appointment was scheduled for follow-up on 5/22/2025 at 10:30 AM. The Continuity of Care Form included a note written by Registered Nurse, Staff A, that wound care supplies were given to the patient upon discharge, although the document did not include patient instructions on how he/she was to care for the wound. During a surveyor interview with the patient’s Registered Nurse, Staff A, on 6/3/2025 at 10:30 AM, he confirmed that he discharged the patient and provided the patient with a bag of dressing supplies. Staff A stated that he instructed the patient to do the dressing the same way that the wound care specialist had done it. Staff A acknowledged that he did not include any dressing instructions, or wound measurements on the patient’s Continuity of Care Form per the hospital’s policy. During surveyor interview with the Wound Care Specialist, Staff B, on 6/3/2025 at 1:00PM, she revealed that she was aware that the patient was going to be discharged soon, however she was not contacted on the day of the patient’s discharge to provide guidance about the patient’s dressing change instructions. Staff B also acknowledged that the Continuity of Care Form did not provide the patient with dressing change instructions per the hospital’s policy.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 43881 Based on record review and staff interviews, it was determined that the hospital failed to ensure that staff who had knowledge of or reasonable cause to believe that a patient had been abused, notified Risk Management immediately in accordance with hospital policy for 1 of 3 patients reviewed for abuse, (Patient ID #1). Findings are as follows: The hospital’s policy titled, “Mandatory Reporting of Patient Abuse & Patient-To-Patient Abuse” last revised in July of 2022 states in part, “ ...Abuse ...intentionally engaging in a pattern of harassing conduct which causes or is likely to cause emotional or psychological harm to the patient or resident, including but not limited to ...cursing directed towards a patient or resident ... Procedure ... ...Any healthcare worker who has knowledge of or reasonable cause to believe that a patient has been abused ...shall notify the Risk Management Department immediately ...” On 4/28/2025, the hospital submitted a report to the Rhode Island Department of Health in which a nurse alleged that she heard another nurse, Employee A, yelling at his patient telling the patient to “f***ing stop” multiple times while giving the patient a bath and changing the linen. During a surveyor interview on 5/1/2025 at 8:46 AM with Employee B, Registered Nurse (RN), she stated that on 4/25/2025 at approximately 4:00 AM, she was inside a patient’s room when she heard “yelling” on the unit. She revealed that she then came out of her patient’s room, onto the hallway and heard Employee A, who was inside Patient’s ID #1’s room behind a closed curtain, yelling, “stop it! f***ing stop!”, and “stop it right now!” She stated that she started to walk toward the yelling and Employee A suddenly opened the curtain and stepped out of the Patient ID #1’s room. She stated that she asked Employee A if he needed help, but he said no. Employee B revealed that Employee A and the patient were the only ones inside the room and the patient was not the one yelling because the patient was “nonverbal” and dependent on staff for assistance. Employee B revealed that she has cared for the patient many times before and stated that the patient “can latch onto you, but it is only a simple hold and is never aggressive.” Record review of the nursing schedule for Employee A, revealed that he continued to work on 4/26/2025 and on 4/27/2025 alongside Employee C, RN. During a surveyor interview on 5/1/2025 at 11:03 AM with Employee C, RN, he confirmed that he worked with Employee A during the overnight shift on 4/26/2025 and on 4/27/2025. Employee C stated that he never saw Employee A provide direct patient care but stated that Employee A was “short with patients over the weekend.” When asked to elaborate, Employee C stated that Employee A was “getting frustrated” and he heard him “speaking loudly to the patients.” When asked to describe Employee A’s tone when speaking to the patients, Employee C stated, “frustrated, seemed angry at times,” and was speaking to the patients in an “angry” tone since the patients had been either pulling and removing their medical devices. During a surveyor interview on 5/1/2025 at 9:59 AM with the Risk Manager, she acknowledged that Employee B did not report Employee A’s behavior to the Risk Management Department immediately in accordance with hospital policy until submitting a report on 4/28/2025, three days after the incident took place.”

“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 record review and staff interviews, it was determined that the hospital failed to ensure that a licensed nurse adhered to the standards of nursing practice related to the removal of a medication from the Omnicell dispensing system under one patient’s name for personal use, using another individual’s identity, (Patient ID #4). Findings are as follows: On 5/6/2025, the Rhode Island Department of Health received an anonymous complaint in which numerous statements were made against Employee D, the Psychiatry Department Manager, one of which alleged that on 5/2/2025, Employee D placed a physician’s order for Ibuprofen 800 milligrams (mg) on Patient ID #4’s medical record without a doctor’s order and under a false provider name. The allegation further stated that Employee D took the medication from the Omnicell and then “returned it.” During a surveyor interview on 5/8/2025 at 9:46 AM with Employee E, Registered Nurse (RN), she explained that on 5/2/2025, Patient ID #4, was complaining of right-sided hip pain and so she reviewed the patient’s medications to see what she could administer. She stated that she saw an order for Ibuprofen to be administered “now” and so she “acknowledged it” in the medical record. She then went to the Omnicell to retrieve the Ibuprofen but was unable to get it as it was no longer “populating” in the system. She then notified the hospital pharmacist who told her at the time that the order did not look like a physician’s order as it was removed as an “override” from the Omnicell. Employee E revealed that she spoke to Employee G, RN, about the Ibuprofen and he notified the Physician, Employee H, who prescribed Tramadol and a lidocaine patch for the patient’s pain instead. Record review of the Omnicell transaction report from 4/7/2025 through 5/7/2025 revealed an entry on 5/2/2025 which indicated that Employee D removed an Ibuprofen (Motrin) 800 mg tablet at 3:16 PM under Patient ID #4’s name. The report then indicated that at 3:17 PM, the Ibuprofen 800 mg tablet was returned to the Omnicell. Record review of the “Order Audit Trail” report for the Ibuprofen tablet confirmed that the tablet was removed from the Omnicell as an override by “Employee F” at 3:16 PM on 5/2/2025, not Employee D. During a surveyor interview on 5/7/2025 at 11:51 AM with the Risk Manager, she revealed that she received a report about Employee D retrieving Ibuprofen from the Omnicell and on the morning of 5/7/2025, she asked Employee D about it. The Risk Manager revealed that Employee D acknowledged that she removed the Ibuprofen from the Omnicell under Patient’s ID #4’s name to give it to a Certified Nursing Assistant on duty and that “it was a bad decision.” During a surveyor interview on 5/7/2025 at 1:11 PM with Employee D, the Psychiatry Department Manager, she was asked about the Ibuprofen she removed from the Omnicell on 5/2/2025 under Patient ID #4, to which she stated that it was “a failed override attempt” and indicated that it was “accidental”, and the patient did not get the Ibuprofen. She stated that she spoke to Pharmacy about it as it was “done in error” under the patient’s name. When asked why she removed the Ibuprofen from the Omnicell under the patient’s name, she stated that it was for “nonbusiness reasons.” When asked what the purpose was for removing the Ibuprofen from the Omnicell if not for business reasons she stated, “possibly for myself, not for a patient.” During an additional interview with the Risk Manager on 5/8/2025, she acknowledged that Employee D should not have removed the Ibuprofen from the Omnicell under Patient ID #4’s name for herself or any of the staff as this is not the standard of practice.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. 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 that patients receive care in a safe setting, for 1 of 1 patient who sustained a fracture, Patient ID #1. Findings are as follows: Record review for Patient ID #1 revealed s/he was admitted to the Psychiatric Unit in December of 2023. The patient was transferred from a long-term care facility with multiple diagnoses including, but not limited to, dementia, schizophrenia, major neurocognitive disorder, and a history of aggressive behaviors. The patient has remained at the hospital while awaiting long-term placement. The patient requires the assistance of 2 staff to transfer from a chair to the bed. Review of a hospital incident report revealed that on 7/24/2024 between 5:00-6:00 AM, the Nurse, Staff F, asked the MHW (Mental Health Worker) Staff D, to take the patient to the bathroom. Staff D asked MHW, Staff E, to assist her. Both Staff D and Staff E were attempting to transfer the patient to a scoot chair (a chair with wheels) to take him/her into the bathroom. The patient was resisting, trying to hit and spit at staff. The hospital incident report states that the Social Worker, Staff I, was called into the patient’s room by the patient on 7/24/2024 at approximately 8:00 AM. Patient ID #1 informed the Social Worker that Staff D had held his/her hand tight during care. A review of the follow up report documented by the hospital Risk Manager states, “ ... [she/he] was trying to strike and spit on them while they were attempting to get [him/her] to the bathroom as requested. Staff D held [his/her] wrist to avoid being hit.” During an interview on 7/30/2024 at approximately 10:20 AM with the Social Worker, she stated that when the patient called her in to tell her about the incident, she observed the patient’s right hand thumb to be bruised and swollen. The Social Worker reported this to the nurse and filed an incident report. The patient was assessed by the Nurse and Nurse Practitioner and an x-ray was ordered. The x-ray report dated 7/24/2024 revealed a fracture involving the medial base of the first proximal phalanx (base of the thumb) with intra-articular extension (extending into the joint). Soft tissue swelling was present. A review of the orthopedic consult dated 7/24/2024 states in part, “avoid weightbearing to the right upper extremity until pain improves, continue immobilizer with volar wrist splint for 3 to 4 weeks, ice elevation ...” During an interview on 7/30/2024 at approximately 9:25 AM, with Nursing Staff F, and Staff H who were on duty at the time of the incident, both denied witnessing the event. During an interview with MHW Staff E at 8:15 AM on 7/30/2024, she stated that Staff D asked her to assist with getting the patient to the bathroom. She stated that the patient was spitting and trying to hit them and she was standing behind the patient and did not hold his/her arms. She reported that Staff D was standing in front of the patient. During an interview with Staff D on 7/30/2024 at 8:45 AM, she stated that she asked Staff E to assist her with the transfer. She reports the patient was not speaking in English, was “flapping [his/her] arms and saying No, No.” She said the patient said she/he wanted to go to church, not the bathroom and was spitting at her. Staff D reported she was trying to bring the patient’s arms down by putting her arms over the patient. She said the patient did not complain of pain when she/he was returned to his/her room from the bathroom. Staff D was asked if she held the patients wrist as was stated in the incident report, but she denied holding or grabbing the patient’s wrist. During surveyor interview with the Risk Manager on 7/30/204 at approximately 1:15 PM, she acknowledged that when the Unit Manager investigated the incident, Staff D initially stated that she held the patient’s wrist to prevent him/her from hitting them. The hospital was unable to produce evidence that the patient received care in a safe setting and failed to provide the patient with the necessary care needed relative to transfers without sustaining an injury. 30526”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 32374 Based on record review, staff interview and hospital policy the hospital failed to follow their policy relative to restraints for 1 of 1 record reviewed for the use of non-violent restraints, Patient ID #2. Findings are as follows: Review of the policy titled “Violent and Non-Violent Restraint” dated 9/2004, revised on 2/17/2024, states in part: “Definitions 1. Restraint: any manual method, physician or mechanical device, material or any equipment or medication that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely... 6. Non-violent restraint: the use of restraint to manage non-violent, non-delf destructive behavior that interferes with treatment or devices necessary to support medical healing. 7. Qualified [Registered Nurse] RN: an RN who has completed specific training to perform evaluation and assessment of patients who may need restraint or seclusion...” “Initiation of Restraint or Seclusion Non-Violent Restraint: The authorized provider or staff member determines the less restrictive interventions to prevent interference with treatment or devices necessary to support medical healing. The authorized provider chooses the type of restraint. The ordering provider either enters the order into the electronic medical record or issues an order to the RN. Order limits - Every 24 hours. Orders may never be “as needed” PRN. The ordering provider performs an in-person assessment of the patient within 24 hours of the initiation of the restraint, and if continued once every 24 hours. Documents the assessment, which includes: The patient’s immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint.” Record review for Patient ID #2, reveals he/she was admitted to the emergency department on 4/15/2024, and transferred to the critical care unit (CCU) on 4/16/2024. On 4/16/2024, the patient had the following orders for non-violent 2-point restraints for preventing him/her from removing the endotracheal tube: The initial order is documented on 4/16/2024 at 11:05 The next order is documented on 4/17/2024 at 17:06 (6 hours over the required 24 hours) The next order is documented on 4/18/2024 at 22:26 (5 and a 1/2 hours over the required 24 hours) The next order is documented on 4/19/2024 at 12:46 The next order is documented on 4/24/2024 at 11:54 (5 days later) The next order is documented on 4/26/2024 at 11:46 (48 hours over the required 24 hours) The last order is documented on 4/27/2024 at 11:39 Further review of the patient’s record revealed the following: Only 4 of the 10 days the patient was in restraints was an in-person assessment completed per the hospital’s policy. The providers face to face encounters were only documented on the 4 dates listed below: 4/16/2024 at 10:30 AM 4/17/2024 at 14:05 (4 hours over the 24 hours) 4/18/2024 at 15:42, (1 ½ hours over the 24 hours) 4/19/2024 at 12:39 During an interview with the Risk Manager on 7/30/2024 at approximately 12:00 PM, she was unable to produce evidence that the restraint orders were renewed every 24 hours as required. Additionally, she was unable to provide evidence of documentation of the restraints from 4/19/2024 through 4/24/2024, or the ordering provider performing an in-person assessment of the patient within 24 hours of the initiation of the restraint, and if continued once every 24 hours. The Risk Manager acknowledged that the hospital failed to follow their policy relative to restraint orders, face to face assessment and documentation requirements. 30526”

“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: 32374 Based on record review and staff interview, it has been determined the hospital failed to ensure that all nursing performance evaluations are completed at least once a year, for 4 of 4 nursing staff whose personnel files were reviewed, Staff D, E, F and H. Findings are as follows: 1. Review of the files for Staff D, a mental health worker (MHW), revealed she was hired in 2021 and her most recent performance evaluation was completed on 4/1/2022. 2. Review of the files for Staff E, a MHW, revealed she was hired in 2018 and her most recent performance evaluation was completed on 4/11/2022. 3. Review of the files for Staff F, a registered nurse (RN), revealed she was hired in 2018 and her most recent performance evaluation was completed on 4/5/2022. 4. Review of the files for Staff H, an RN who was hired in 2021, revealed her most recent performance evaluation was completed on 6/21/2022. During surveyor interview with the risk manager on 7/30/2024 at approximately 11:50 AM, when questioned about the lack of annual performance evaluations, she informed the surveyor that the hospital only completes performance evaluations once every three years. Additionally, she provided the surveyor with a copy of the hospital’s policy titled, “Employee Performance Review Process’ which is dated 6/1/2017 and revised on 6/30/2023, which states in part: “Performance evaluations are completed on the calendar year but not to exceed three years for all eligible employees...” The hospital failed to provide annual nursing evaluations as required by federal regulation. 30526”

“PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT CFR(s): 482.13(g)(1) & (3)(i) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time.”Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.... (3) The staff must document in the patient’s medical record the date and time the death was: (i) Reported to CMS for deaths described in paragraph (g)(1) of this section; or .... This Standard is not met as evidenced by: 45769 Based on record review and staff interview it has been determined that the hospital failed to report a hospital death associated with the use of restraints to CMS no later than the close of business on the next business day following knowledge of a patient’s death, for 1 of 1 patients whose death occurred within 24 hours after restraint removal. Findings are as follows: Review of the patient’s Emergency Room Progress Notes dated 1/26/2024 revealed the following: -4:50 PM: The patient was placed in four point restraints “attempting to jump off bed, and spit, scratch, and pitch staff.” -5:36 PM: The patient was found unresponsive and “had a cardiac arrest while in restraints in the ED [Emergency Department]” -5:38 PM: “Compressions began” -7:05 PM: “ROSC” (Return of Spontaneous Circulation) Review of the patient’s electronic medical record revealed a physician’s note dated 1/27/2024 at 1:48 PM indicating that the patient expired, listing date and time of death as 1/27/2024 at 1:42 PM. Additional record review revealed a Medical Provider Note dated 2/16/2024 which stated that on 2/16/2024 at 3:00 PM, form CMS-10455 was submitted which reported a death within 24 hours of the removal of a restraint. During a surveyor interview with the Systems Manager on 2/29/2024 at 10:00 AM, she acknowledged that she reported the death late because she did not learn that the patient had been in restraints within 24 hours of their death until 2/26/2024.”