Newport Hospital

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43881 Based on clinical record review and staff interviews, the hospital failed to ensure physician orders were obtained immediately following the use of a physical escort, a physical hold, and a restraint chair for 1 of 6 patients reviewed, Patient ID #1. Findings are as follows: The hospital’s policy titled, “Patient Restraint and Seclusion,” defines restraints as “Any intrusive method of suppressing the ability of the person to move their arms, legs, body, or head freely; or have normal access to their body due to equipment attached to, or adjacent to the patient...” The policy also defines a violent restraint as “The use of restraint or seclusion when warranted by violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others.” The policy further states that “If the ordering provider is not present, the RN [Registered Nurse] will contact the ordering provider to obtain the order” and “In an emergency situation where the order cannot be obtained prior, the order must be obtained during the emergency application of restraint or immediately after (within minutes) the restraint was initiated. If an order is not obtained immediately, it will be considered restraint without an order.” A complaint submitted to the Rhode Island Department of Health alleged in part that Patient ID #1 was picked up by a male, slammed onto a bed and held “down so hard” causing bruising to their wrists and ankles. The complaint further alleged that Patient ID #1 was picked up again and placed in chair “where they aggressively strapped me in” which resulted in “cuts and bruising.” Clinical record review revealed that Patient ID #1 presented to the Emergency Department at Newport Hospital in November of 2025 due to suicidal ideations with a plan to overdose on prescribed medications. According to the clinical record, the patient was placed under emergency certification due to the severity of their symptoms and an inability to develop a safety plan. Further review revealed that after the patient was informed of their emergency certification status, she/he exited his/her room yelling at staff requesting to return home. After multiple attempts were made at calming the patient, nursing and security personnel placed the patient back in their room on their bed and proceeded to restraint the patient onto the bed. Clinical record review revealed that at 6:30 PM on 11/30/2025 the patient was applied a 4-point violent restraints while on the bed which involved securing the right and left wrists and the right and left lower extremities. Further record review revealed that the patient began to slip out of the 4-point violent restraint and was then transitioned to a restraint chair by 6:36 PM which was removed by 6:45 PM. During a surveyor interview on 12/16/2025 at 2:57 PM with Employee A, Registered Nurse, she confirmed that she and a security guard physically escorted the patient and lifted him/her while a third person secured the patient’s legs. Employee A stated that the patient was “picked up a little bit” and placed onto the bed where four-point restraints were applied. During a surveyor interview on 12/17/2025 at 9:52 AM with Employee B, Security Guard, he confirmed that he picked up the patient, placed him/her on the bed and held him/her there while nursing staff administered injections. He explained that he lifted the patient by placing his arms and hands under the patient’s armpits, maintaining control over the patient’s upper body. He stated that the patient was “dead weighting,” and confirmed that the patient’s feet left the ground when he picked him/her up. Additionally, he stated that the patient continued to kick and repeatedly said, “[profanity] let me go.” During a surveyor interview on 12/17/2025 at 9:14 AM with Employee C, Registered Nurse, she explained that Patient ID #1 was guided onto the restraint chair and confirmed that the restraint straps were applied. Employee C further explained that when a patient is placed in a restraint chair their legs, arms, and waist are strapped and a last strap goes over their shoulders. During a surveyor interview on 12/17/2025 at 10:13 AM with the Risk Manager, she confirmed that Employee D, Security Guard, and Employee A positioned themselves on the patient’s sides and while the patient was pushing back, Employee B came up from behind the patient and the patient’s legs went “up in the air” and she/he was “flailing.” The Risk Manager confirmed that the patient was picked up by Employee B and placed on the bed while someone else assisted with the patient’s feet. The patient’s medical record failed to reveal evidence that a physician order was obtained immediately after the patient was physically escorted to his/her room and physically held for the administration of injections prior to the placement of four-point restraints, in accordance with federal regulations and hospital policy. The medical record further failed to reveal evidence that a physician order for application of a restraint chair was obtained immediately after the restraint was applied. During a surveyor interview on 12/17/2025 at 10:38 AM with the Clinical Nurse Specialist/Educator, she acknowledged that if a patient is pushing back and is being moved against their will, it is considered a restraint and expects this to be reflected in the physician’s order. Additionally, she indicated that she would have expected the restraint chair to be included in the physician’s order since the physician has the ability to select different restraint types in the same order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 43881 Based on clinical record review and staff interviews, the hospital failed to ensure that staff monitored the condition of restrained patients in accordance with hospital policy. Specifically, staff failed to conduct a face-to-face assessment within 24 hours after the renewal of a non-violent restraint for Patient ID #2. Additionally, staff failed to document an initial assessment after restraint initiation for Patient ID #3 and every 15 minutes thereafter for both Patient ID #s 3 and 4 in accordance with hospital policy for 3 of 6 patients reviewed. Findings are as follows: The hospital’s policy titled, “Patient Restraint and Seclusion,” defines non-violent restraint as “The use of restraint to manage non-violent, non-self-destructive behavior that interferes with treatment or devices necessary to support medical healing” and violent restraint as “The use of restraint or seclusion when warranted by violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others.” Further, the policy states in part that for non-violent restraints, the ordering provider performs a face-to-face assessment of the patient, within 24 hours of the initiation of the restraint” and for violent restraints, Registered Nurses “assess at initiation and every 15 minutes thereafter.” The policy further stated that the Registered Nurse “ensures that the assessment is documented and addresses: - If discharge criteria is met and need for continued restraint or discontinuation - Physical and psychological status and comfort of the patient - Response to restraint - Correct application/position of restraint (as applicable) - Signs of injury - Skin integrity: circulation, sensation, movement (CSM) of restrained extremities, as applicable - Range of Motion performed as applicable - Level of consciousness (LOC) - Nutrition and Hydration - Hygiene and elimination - Respiratory - Vital signs 1. Clinical record review revealed that Patient ID #2 was admitted to the hospital in September of 2025 due to altered mental status. The clinical record indicated that the patient required the use of non-violent right and left wrist restraints between 9/7/2025 through 9/14/2025 as she/he was interfering with medical interventions. The record indicated that an order renewal for this type of restraint was obtained on 9/10/2025. However, the record failed to reveal evidence of a documented face to face assessment of the patient by the ordering provider. During a review of clinical records with the Clinical Nurse Specialist/Educator on 12/17/2025 at 12:00 PM, she confirmed that she was unable to locate a documented face to face assessment for Patient ID #2 on 9/10/2025 after the non-violent restraint was reordered. 2. Clinical record review revealed that Patient ID #3 presented to hospital in October of 2025 due to chest pain, vomiting, and drug use. According to the patient’s medical record, at approximately 5:15 AM on 10/20/2025, the patient attempted to harm themselves with a needle used to insert intravenous lines that she/he retrieved from a cart in the Emergency Department. The record indicated that the patient required restraints following their self-harm attempt. Record review of nursing documentation revealed that security officers had to “put hands on the patient and put [him/her] on the ground ...” Further review revealed that the patient was then applied 4-point restraints at 5:24 AM while on the bed which involved securing the right and left wrists and the right and left lower extremities. Further review of nursing progress notes revealed that the patient was unable to remain safe while on 4-points restraints as she/he tried to hit their head against the bed and attempted to bite the railings as well. The patient was then removed from 4-point restraints and transitioned to a restraint chair at 5:40 AM. The clinical record failed to reveal evidence that a Registered Nurse conducted an assessment in accordance with hospital policy at the time the restraint chair was initiated as well as every 15 minutes thereafter for a total of 3 opportunities. The patient was not assessed by a Registered Nurse until 6:40 AM. During a review of clinical records with the Clinical Nurse Specialist/Educator on 12/17/2025 at 1:01 PM, she acknowledged that the patient’s restraint documentation was missing nursing assessments. 3. Clinical record review revealed that Patient ID #4 presented to hospital in October of 2025 after attempting to dive through a window. The clinical record indicated that the patient required the use of violent restraints, including chemical and limb restraints, after becoming agitated and combative with staff. The record revealed that restraints were initiated on 10/12/2025 at 9:29 PM and eventually discontinued by 1:16 AM on 10/13/2025. During a review of clinical records with the Clinical Nurse Specialist/Educator on 12/17/2025 at 1:31 PM, she confirmed that although vital signs were consistently obtained for Patient ID #4, the violent restraint flowsheet was missing documentation of the required 15-minute nursing assessments for multiple time intervals.”

“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 Based on a review of hospital policies, patient records, and staff interviews, the hospital failed to ensure that a patient’s discharge plan was consistent with their goals for post-discharge care after the hospital failed to ensure a provider arranged the appropriate post-surgery follow-up including the removal of surgical staples and wound care in accordance with the patient’s discharge needs (A-0813).”

“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 record review and staff interviews, the hospital failed to ensure that discharge instructions were documented in accordance with hospital policy for 1 of 4 patients reviewed who underwent surgical procedures at the hospital (Patient ID #2). Additionally, Patient ID #2’s medical record failed to reveal evidence that arrangements were made with the appropriate provider for the removal of surgical staples and wound care in accordance with the patient’s discharge needs following surgery. Findings are as follows: A complaint submitted to the Rhode Island Department of Health alleged in part that a upon discharge, the Physician (Employee A) gave Patient ID #2 a staple remover and told him/her to “find someone to remove the staples in a few days or watch a video and do it yourself.” Record review revealed that Patient ID #2 presented to the hospital in April of 2025 complaining of abdominal pain. The patient was subsequently admitted for surgery after diagnostic imaging confirmed evidence of acute appendicitis (inflammation of the appendix). The record indicated that on 4/19/2025, Patient ID #2 initially underwent a laparoscopic appendicectomy (a surgical procedure used to remove inflamed appendix), however, during the initiation of this surgery, it was determined that the patient’s appendix had perforated, and the surgery was converted into an open ileocolectomy (a surgical procedure used to remove sections of the small and large intestines). A “midline incision was made above the umbilicus (navel)” and parts of the intestines were removed, the internal suturing was applied, and the skin was closed with “staples.” Review of Patient ID #2’s medical record failed to reveal documentation of the wound status at discharge, nor evidence that arrangements were made for surgical follow-up, wound evaluation, or staple removal. Additionally, the record failed to reveal documentation that the patient had been instructed to monitor for wound complications or signs of infection, nor were wound care instructions documented. During a surveyor interview with Patient ID #2 on 9/19/2025 at approximately 10:45 AM, the patient presented a photo of their surgical incision taken approximately two days following discharge from the hospital. The image showed a midline abdominal incision extending above the navel. Approximately seven surgical staples were clustered near the navel. The image revealed that there were only two staples along the superior portion of the incision line, with three open areas where the skin edges were not close together resulting in exposed underlying tissue. During a surveyor interview with the Director of Risk Management on 9/18/2025 at approximately 2:00 PM, she was unable to provide evidence that Employee A documented Patient ID #2’s discharge instructions related to wound care, signs of infection and complications, and follow up arrangements for wound evaluation and staple removal, in accordance with hospital policy.”

“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 that the hospital failed to follow their policy related to the documentation of a new pressure wound for 1 of 5 patient’s reviewed for pressure ulcers, Patient ID #1. Findings are as follows: A community reported complaint was submitted to the Rhode Island Department of Health on 4/17/2024 from the patient’s family member alleging that Patient ID #1 needed surgery to clean out an infected wound. Review of the hospital policy titled, “Wound Assessment/Reassessment and Nursing Protocol Orders for Impaired Skin Integrity” last reviewed on 9/2023, states in part: Policy ... ...3. All wounds which require ongoing assessment shall be added as a single wound LDA (Lines, Drains, Airway, Tubes and Wounds) [a section in the nursing flow sheet to document assessment/care provided by the nurse] with the wound type specified in the LDA properties in the electronic health record ... Procedures ... ...2. Initiation of Wound LDA ... documentation should include. wound type, present on admission ... ...3. Wound Assessment ... document wound characteristics ... Record review for Patient ID #1 revealed this patient presented to the hospital for rehabilitation on 2/24/2024, as a transfer from another hospital after sustaining an incomplete spinal cord injury while swimming. Review of the initial nursing admission assessment on 2/24/2024 revealed that both the patient and family member are hearing impaired. Patient ID #1 is alert and oriented X 4. On admission (2/24/2024) the patient was noted to have an open blister on his/her right upper and lateral thigh and an open blister to right inner thigh, with small intact blisters noted on the trunk related to generalized swelling. A Review of the patient’s Plan of Care revealed a nursing note dated 2/27/2024 at 2:40 PM, noting the following new wound area was identified “scattered open/dry blisters noted to peri area bilateral thighs and buttocks”. Notes indicate a foam adhesive dressing was applied to the wound, but per the hospitals policy the nurse failed to initiate a Wound LDA which would identify and describe each wound separately. Records indicate the first documentation of the wound LDA (a wound description and measurement) did not occur until 3/4/2024 (7 days after being identified), as new open blister on the patient’s left buttock. During a surveyor interview on 4/23/2024, with Certified Wound Nurse Staff H, she stated that it was her expectation that on 2/27/2024 when the wound was first identified, the nurse should have initiated the wound LDA documentation of the newly identified area on the patient flow sheet. When asked if she would have recommended a different treatment, she stated she would not. During a surveyor interview with the Risk Manager on 4/23/2024, she was not able to provide evidence that when the nurse identified the new skin wound on 2/27/2024, it was added to the patient’s hospital record in the flowsheet as per hospital policy. 45769”