Rhode Island Hospital

“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: 32374 Based on review of hospital policies, clinical record review, and staff interviews, the hospital failed to ensure the provision of nursing services in accordance with 42 CFR §482.23, Condition of Participation: Nursing Services. This was evidenced by the hospital’s ongoing failure to ensure nursing staff appropriately responded to an electronic medication safety alert indicating that a dose of Lispro insulin was being administered too soon. As a result, Patient ID #1 received a duplicate dose of Lispro insulin within 31 minutes of the previous administration. (Refer to A-0405.) On 7/16/2026 at approximately 12:15 PM, the survey team determined that the deficient practice constituted Immediate Jeopardy (IJ) under 42 CFR §482.23, Nursing Services, because the hospital’s failure to ensure appropriate nursing response to medication safety alerts placed patients at risk for serious injury, harm, impairment, or death. On 7/16/2026, the hospital submitted an Immediate Plan of Correction (IPOC) describing the actions it would implement to remove the Immediate Jeopardy and prevent recurrence. The IPOC included the following corrective actions: On 7/16/2026, hospital leadership, including the Chief Medical Officer, Chief Nursing Officer, Associate Chief Nursing Officer, System Director of Nursing Education, Risk Management, Accreditation and Regulatory Readiness, and Quality and Safety, met to review the medication error event and develop an immediate corrective action plan. Effective 7/16/2026, the Nursing Department developed and distributed a system-wide SWAY communication highlighting the recent medication errors and the updated medication administration practice alert. The communication instructed staff that compliance with the revised practice alert was effective immediately and included links to the hospital’s Code of Conduct and Professional Standards policies. Effective 7/16/2026, the hospital revised the electronic Medication Administration Record (MAR) “Medication Too Soon” Practice Alert by implementing a required hard stop. The revised alert changed the visual indicator to a stop sign and strengthened the warning language to state: “WARNING: Potential Medication Error-This medication dose may be too soon. You must review the last administration to determine if this dose is appropriate to administer at this time.” The revised alert also required staff to document an acknowledgment reason and attest, by initials, that the medication being administered was not a duplicate dose before proceeding. Effective 7/16/2026, the Pharmacy Alert Team began reviewing medication alert data to identify additional electronic alerts requiring evaluation and to develop recommendations for further system enhancements to improve medication administration safety and compliance. On 7/17/2026 at approximately 9:45 AM, the State Survey Agency verified implementation of the immediate corrective actions and determined that the Immediate Jeopardy had been abated. 45769”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 32374 Based on policy review, medical record review, electronic medication administration record (eMAR) review, pharmacy review, and staff interviews, it was determined that the hospital failed to ensure nursing staff appropriately responded to electronic medication safety alerts and failed to ensure compliance with the hospital ’ s policy titled, “Medication Administration, System Admin 110,” for 1 of 5 patients reviewed for insulin administration (Patient ID #1). This failure resulted in the administration of a duplicate dose of insulin lispro, placing the patient at risk for an adverse medication event. Findings are as follows: Review of the hospital policy titled “Medication Administration, System Admin 110,” last revised August 2025, revealed the policy states in part: “Eight Rights of Medication Administration Practice” Right Patient Right Medication: Ensure that the medication being given matches what has been prescribed. Right Dose: Ensure that the dosage of the medication matches. Right Route Right Time Right Documentation: Confirm when the last dose was given. Right Reason Right Response Review of Patient ID #1 ’ s clinical record revealed the patient had end-stage renal disease and received dialysis three times weekly. The patient also had a diagnosis of type 2 diabetes mellitus and was prescribed a bedtime dose of Lantus insulin, a scheduled dose of Lispro insulin three times daily with meals, and a Lispro sliding scale based on blood glucose levels. Review of a Significant Event Note dated 7/14/2026 at 5:38 PM, documented by hospitalist physician Employee E, revealed the patient ’ s sister reported that the patient had received the lunchtime dose of Lispro insulin twice the previous day. During an interview on 7/15/2026 at 11:30 AM with the Director of Pharmacy Quality and Safety (Employee A) and the Director of Inpatient Pharmacy (Employee B), Employee B stated that the medication error was identified by pharmacy after reviewing the patient ’ s medication profile due to a blood glucose level of 65 mg/dL approximately five hours after the lunchtime insulin administration. Pharmacy review identified that Patient ID #1 received 14 units of insulin lispro at 1:01 PM on 7/13/2026 administered by Staff Nurse Employee C and received a second, duplicate dose of 14 units of insulin lispro at 1:32 PM on 7/13/2026 administered by Staff Nurse Employee D. The medication error was reported immediately through the hospital ’ s Safety Net reporting system and communicated to the patient ’ s physician. Pharmacy staff provided evidence that both nurses received an electronic medication safety alert during medication administration indicating that the medication “may be too soon” to administer. During an interview on 7/16/2026 at 9:17 AM, Employee C stated that another nurse (Employee J) had left the unit to accompany another patient, and she and Employee D were covering Employee J ’ s assigned patients. Employee C stated she entered Patient ID #1 ’ s room and administered the patient ’ s insulin. While she was in the room, Employee D entered, and Employee C informed Employee D that she was administering the patient ’ s insulin. Employee C stated she was notified the following day that an insulin administration error had occurred. Upon review, it was discovered that the patient ’ s scheduled lunchtime insulin dose had been documented under the breakfast medication administration record. Employee C stated that the insulin sliding scale dose was correctly documented as administered at 1:01 PM, indicating that 4 units of insulin were administered based on the patient ’ s blood glucose level. During an interview on 7/16/2026 at 9:35 AM, Employee D stated she was the charge nurse on 7/13/2026. Employee D confirmed she observed Employee C administering medication to Patient ID #1; however, after reviewing the patient ’ s medication administration record, she noted that the sliding scale insulin had been administered and believed the scheduled lunchtime Lispro dose of 14 units was overdue. Employee D stated she subsequently administered 14 units of Lispro insulin to Patient ID #1 at 1:32 PM. Employee D confirmed that the electronic medication alert indicating the medication “may be too soon” appeared during administration. Employee D stated she bypassed the alert because she believed the alert appeared routinely when a sliding scale dose and scheduled insulin dose were administered close together. Employee D stated she was unaware that the alert displayed information regarding the previous insulin dose and the time it had been administered. During an interview on 7/15/2026 at 1:44 PM, Employee J stated that Patient ID #1 did not want to wake up and eat breakfast on 7/14/2026. Employee J explained that the patient ’ s scheduled breakfast Lispro insulin order directed staff to hold the insulin if the patient was not eating breakfast. Employee J stated that the sliding scale insulin was based on the patient ’ s current blood glucose level and that at 11:07 AM she documented in the Medication Administration Record that the patient did not require sliding scale insulin. Employee J acknowledged that she did not document that the scheduled breakfast Lispro insulin dose was held. Employee J stated that once the patient’s meal tray was removed, she would normally document that the insulin was not administered and notify the provider. Employee J stated that at dinnertime the patient’s blood glucose level was reported as 65 mg/dL. The physician was notified, the patient received glucose gel, and the scheduled insulin dose was held. Employee J stated she was not aware at that time that the patient had received a duplicate dose of insulin lispro during lunchtime. The hospital failed to ensure nursing staff followed established medication administration procedures, including review and appropriate response to electronic medication safety alerts and verification of the right medication, right dose, right time, and right documentation prior to insulin administration. As a result, Patient ID #1 received a duplicate dose of scheduled insulin lispro, increasing the risk for hypoglycemia and potential patient harm. 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: 45769 Based on record review, policy review, observations, and staff interviews, it was determined that the hospital failed to ensure its Nursing Service was organized and staffed to provide safe, competent nursing care that met the needs of patients requiring specialized respiratory care. These systemic failures resulted in the hospital’s inability to ensure that a chronic ventilator-dependent patient received appropriate nursing assessment, monitoring,care by competent staff, and adequate clinical oversight necessary to prevent adverse patient outcomes. Specifically, the hospital failed to: 1. Ensure nursing care was provided with care in a setting that was safe and appropriate to the patient’s identified respiratory and nursing care needs. (Tag A-0144); 2. Ensure the nursing service assigned registered nurses with the experience and qualifications necessary to safely care for a medically complex patient requiring specialized ventilator management (Tag A-0397); 3. Ensure nursing services were organized to provide appropriate patient placement, physiologic monitoring, and nursing oversight consistent with the patient’s acuity and their inability to call for assistance (Tag A-0395).”

“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 review of the medical record, hospital policies and procedures, staff education and competency records, and interviews with hospital staff and the patient’s attending pulmonologist, it was determined that the hospital failed to provide Patient ID #2, a nonverbal, non-ambulatory, chronically ventilator-dependent patient, with care in a setting that was safe and appropriate to the patient’s identified respiratory and nursing care needs. Findings are as follows: Patient ID #2 was a patient with a medical history including cerebral palsy, chronic tracheostomy with mechanical ventilator dependence, gastrostomy tube dependence, hydrocephalus status post ventriculoperitoneal shunt, epilepsy, abscesses, and prior small bowel obstruction. The patient was unable to move independently or communicate needs or summon assistance and was completely dependent on caregivers for activities of daily living and recognition of changes in condition. Review of the Admission History and Physical dated 5/7/2026 revealed that Patient ID #2 was admitted for inpatient treatment of a left shoulder abscess and remained dependent on his/her home mechanical ventilator while hospitalized on a general medical unit. Review of the hospital policy titled “Mechanical Ventilation,” last revised 1/2026, revealed that home ventilators could be used for hospitalized patients. The policy stated, in part, that if staff were unfamiliar with operation of a home ventilator, Respiratory Therapy could transition the patient to a hospital-owned ventilator. The policy did not establish specific nursing monitoring requirements, competency requirements, or escalation criteria for patients maintained on home ventilators outside of a critical care setting. During an interview on 7/8/2026, the Manager of Respiratory Care (Employee C) stated that Patient ID #2 was considered a chronic ventilator-dependent patient. He stated that Respiratory Therapy performed ventilator assessments every 4 to 6 hours and that the respiratory therapist assigned to the patient was also responsible for patients on multiple inpatient units and was available by pager. He further stated that tracheostomy care was a shared responsibility between Respiratory Therapy and nursing. He confirmed that the hospital did not maintain a separate competency program specific to home ventilator management. Review of Respiratory Therapy documentation revealed ventilator checks were performed approximately every 4 to 6 hours, with the last documented respiratory therapy assessment occurring at 9:11 PM on 5/10/2026. During an interview on 7/8/2026, the patient’s assigned registered nurse (Employee G) stated that this was her first experience caring for a patient on a home ventilator and that she had cared for only one ventilated patient previously. She stated that when the ventilator alarmed, she contacted Respiratory Therapy because she relied upon Respiratory Therapy to troubleshoot the ventilator. Review of the travel nurse’s Skills Checklist for Employee H dated 9/23/2025 revealed that the nurse self-reported only intermittent experience with ventilator care, tracheostomy management, and chronic/stable ventilators. The checklist defined “intermittent” as “May need support or supervision.” Review of Employee H’s Symplr Learning Record dated 2/17/2026 and Travel Registered Nurse Competency Record dated 2/16/2026 revealed no documented education, competency validation, or training related to ventilator management or tracheostomy care. During an interview on 7/8/2026, Nursing Leadership (Employee I) was unable to provide evidence that the assigned travel nurse had completed hospital-specific orientation or competency validation for ventilator or tracheostomy management. The Director of Medical Nursing further confirmed that tracheostomy care was not included in the hospital’s current annual nursing competency program. During an interview on 7/9/2026, a registered nurse who cared for Patient ID #2 on 5/7/2026 and 5/8/2026 (Employee J) stated that the patient required extensive nursing care, including inline suctioning, home ventilator management, complete assistance with hygiene and incontinence care, and two staff members for repositioning. Employee J confirmed that the patient was unable to move or communicate and stated that when the ventilator alarmed during care, she immediately paged Respiratory Therapy to troubleshoot the ventilator. Review of a Significant Event Note entered by Employee H on 5/10/2026 at 11:16 PM documented: “RN was assessing another patient, home ventilator was alarming, RN checked patient pulseless, code called.” Review of physician documentation dated 5/10/2026 and 5/11/2026 revealed that ventilator disconnection was identified as one of the suspected causes of the patient’s hypoxia and subsequent pulseless electrical activity cardiac arrest. Return of spontaneous circulation was achieved following cardiopulmonary resuscitation and administration of two doses of epinephrine. During an interview on 7/8/2026, the patient’s attending pulmonologist (Employee D) stated that he would expect a chronically ventilator-dependent patient admitted to a general medical unit to receive continuous cardiac monitoring and continuous pulse oximetry because of the patient’s respiratory dependence. Review of the physician admission orders revealed that continuous cardiac monitoring, telemetry, continuous pulse oximetry, or constant observation were not ordered for Patient ID #2 while the patient was cared for on the general medical unit. The hospital failed to ensure that Patient ID #2 was cared for by nursing staff with demonstrated competency and sufficient experience to meet the patient’s specialized ventilator and tracheostomy care needs. The patient was unable to communicate respiratory distress, summon assistance, respond to a ventilator alarm, or independently protect himself/herself from the consequences of ventilator disconnection. Despite these known risks, the patient was cared for in a general medical unit where the assigned nursing staff had limited ventilator experience, no documented competency validation for ventilator or tracheostomy management was available, and Respiratory Therapy was not continuously present at the bedside but was responsible for patients on multiple inpatient units and available by pager. The failure to provide an appropriately safe care environment was demonstrated on 5/10/2026 when the patient’s home ventilator alarmed while the RN was assessing another patient. Patient ID #2 was subsequently found pulseless and required cardiopulmonary resuscitation and administration of two doses of epinephrine. Physician documentation identified ventilator disconnection as a suspected cause of the patient’s hypoxia and pulseless electrical activity arrest. Based on the patient’s complete dependence on mechanical ventilation, inability to communicate or summon assistance, need for specialized respiratory and nursing care, lack of documented competency validation for assigned nursing staff, limited availability of Respiratory Therapy, absence of defined nursing monitoring requirements for patients maintained on home ventilators outside of critical care, and occurrence of an unwitnessed ventilator-related emergency resulting in cardiac arrest, the hospital failed to provide care in a setting that a reasonable person similarly situated as the patient would consider safe. 45769”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 45769 Based on record review, observation, hospital policy review, staffing records, and staff interviews, it was determined that the hospital failed to ensure that nursing services were organized and staffed to provide nursing care necessary to meet the documented needs of Patient ID #2, a chronically ventilator-dependent patient who required specialized nursing care related to mechanical ventilation and tracheostomy management. Findings are as follows: Review of the clinical record for Patient ID #2 revealed the patient was a 25-year-old with cerebral palsy, chronic tracheostomy, chronic ventilator dependence, hydrocephalus, and epilepsy. The patient was nonverbal, unable to move independently, and dependent on staff for care, including the ability to communicate needs or summon assistance. Review of the admission record revealed Patient ID #2 was admitted on 5/7/2026 at 12:08 AM to JB-1 North, a general medical inpatient unit, while remaining dependent on his/her home ventilator. Review of the patient’s clinical documentation revealed that nursing care included management of the home ventilator, inline suctioning, complete assistance with hygiene and incontinence care, and two staff members for repositioning. Review of staffing schedules for May 7 through May 10, 2026, revealed JB-1 North was staffed with five registered nurses and three nursing assistants on the day shift and five registered nurses and two nursing assistants on the night shift. During interview on 7/9/2026, the Manager of Operations, Capacity Management and Access Center (CMAC) (Employee K), stated that patient placement was based on the physician-ordered level of care. She stated that CMAC could consult Nursing Operations regarding staffing or patient acuity but could not confirm that Nursing Operations had been consulted before Patient ID #2 was placed on JB-1 North. During interview on 7/9/2026, the Manager of Nursing Operations (Employee L) confirmed that Nursing Operations had not been contacted regarding Patient ID #2’s placement. She stated that concerns regarding patient placement were often identified after patients arrived at the nursing unit because CMAC did not routinely involve Nursing Operations unless a consultation was requested. During interview on 7/8/2026, the patient’s assigned registered nurse (Employee G) stated that this was her first experience caring for a patient on a home ventilator and that she had cared for only one ventilated patient previously. She stated that when the ventilator alarmed, she contacted Respiratory Therapy who are not always available on the unit to troubleshoot the ventilator. Review of the travel nurse’s Skills Checklist for (Employee H) dated 9/23/2025 revealed that the nurse self-reported only intermittent experience with ventilator care, tracheostomy management, and chronic/stable ventilators. The checklist defined “intermittent” as “May need support or supervision.” Review of Employee H’s Symplr Learning Record dated 2/17/2026 and Travel Registered Nurse Competency Record dated 2/16/2026 revealed no documented education, competency validation, or training related to ventilator management or tracheostomy care. During interview on 7/8/2026, Nursing Leadership (Employee I) was unable to provide evidence that the assigned travel nurse had completed hospital-specific orientation or competency validation for ventilator or tracheostomy management. The Director of Medical Nursing further confirmed that tracheostomy care was not included in the hospital’s current annual nursing competency program. During interview on 7/8/2026, the Manager of Respiratory Care (Employee C) stated that Respiratory Therapy performed ventilator assessments every 4 to 6 hours and that the respiratory therapist assigned to Patient ID #2 was also responsible for patients on multiple inpatient units and was available by pager. He further stated that tracheostomy care was a shared responsibility between Respiratory Therapy and nursing. Review of the clinical record revealed that on 5/10/2026, Patient ID #2’s home ventilator alarmed. The patient was subsequently found pulseless, requiring activation of a Code Blue, cardiopulmonary resuscitation, and transfer to the Coronary Care Unit. Physician documentation identified ventilator disconnection as one of the suspected causes of the patient’s hypoxia and cardiopulmonary arrest. The hospital failed to demonstrate that nursing services were organized to ensure that nursing personnel assigned to Patient ID #2 possessed the competency and experience necessary to perform the specialized nursing care required by the patient’s chronic ventilator and tracheostomy dependence. The assigned registered nurse had limited prior ventilator experience, self-reported that ventilator and tracheostomy care were areas in which she might require support or supervision and had no documented hospital competency validation for ventilator or tracheostomy management. The hospital also did not demonstrate that Nursing Operations was consulted regarding the patient’s placement or the nursing resources and competencies necessary to meet the patient’s documented care needs.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 45769 Based on record review, personnel file review, and staff interviews, it was determined that the hospital failed to ensure the assignment of nursing personnel with the experience and competency necessary to meet the specialized nursing needs of a chronic ventilator-dependent patient. Specifically, the hospital assigned a travel registered nurse without demonstrated competency in ventilator and tracheostomy management to provide care for a patient requiring specialized respiratory care. This deficient practice placed the patient at risk for failure to recognize changes in condition and respond appropriately to ventilator-related emergencies. Findings are as follows: Review of Patient ID# 2 clinical record revealed the patient was a 25-year-old with cerebral palsy, chronic tracheostomy, and chronic ventilator dependence who was admitted to a general medical unit on 5/7/2026 at 12:08 AM. The patient was nonverbal, unable to move, required total care, and depended entirely upon his ventilator for respiratory support. During a surveyor interview on 7/8/2026, with one of the patient’s assigned registered nurses (Employee G) she stated this was her first experience caring for a patient on a home ventilator and that she had cared for only one ventilated patient previously. She stated that when the ventilator alarmed she would contacted Respiratory Therapy because she relied on the respiratory therapist to troubleshoot the ventilator. Review of the travel nurse’s Skills (Employee H) Checklist, dated 9/23/2025, revealed the nurse self-reported only intermittent experience with: Ventilator care; Tracheostomy management; and Chronic/stable ventilators. The checklist defined “Intermittent” as “May need support or supervision.” Review of the hospital policy titled “Mechanical Ventilation,” last revised 1/2026, revealed that home ventilators could be used for hospitalized patients. The policy stated, in part, that if staff were unfamiliar with operation of a home ventilator, Respiratory Therapy could transition the patient to a hospital-owned ventilator. The policy did not establish specific nursing monitoring requirements, competency requirements, or escalation criteria for patients maintained on home ventilators outside of a critical care setting. During an interview on 7/8/2026, the Manager of Respiratory Care (Employee C) stated that Respiratory Therapy performed ventilator assessments every 4 to 6 hours and that the respiratory therapist assigned to the patient was also responsible for patients on multiple inpatient units and was available by pager. He further stated that tracheostomy care was a shared responsibility between Respiratory Therapy and nursing. Review of (Employee H’s) Symplr Learning Record (a healthcare-focused learning management system that streamlines staff training, compliance tracking, and competency management), dated 2/17/2026, and Travel Registered Nurse Competency Record, dated 2/16/2026, revealed no documented education, competency validation, or training related to ventilator management or tracheostomy care. During interviews on 7/8/2026, (Employee I) Nursing Leadership was unable to provide evidence that the assigned travel nurse had completed hospital orientation or competency validation for ventilator or tracheostomy management. The Director of Medical Nursing further confirmed that tracheostomy care was not included in the hospital’s current annual nursing competency program. During interview on 7/8/2026, the Manager of Respiratory Care (Employee C) who confirmed the hospital does not maintain a separate competency program for home ventilators, and frequently require vendor representatives to provide education regarding their operation on site due to multiple types of home ventilators that are used in the community. Review of Patient ID# 2’s record revealed that on 5/10/2026, the patient was found pulseless, requiring activation of a Code Blue, cardiopulmonary resuscitation, and transfer to the Coronary Care Unit. Documentation identified ventilator disconnection as one of the suspected causes of the patient’s cardiopulmonary arrest. Based on these findings, the hospital failed to ensure that a registered nurse with the necessary knowledge, experience, and demonstrated competency was assigned to provide nursing care to a medically complex, chronically ventilator-dependent patient requiring specialized respiratory management.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 45769 Based on policy review, medical record review, pharmacy records, and staff interviews, it was determined that the hospital failed to administer medications in accordance with hospital policy for 1 of 2 patients reviewed for methadone administration (Patient ID #3). This failure resulted in Patient ID #3 receiving two doses of Methadone 180 mg on 6/25/2026. Findings are as follows: Review of the hospital policy, “Medication Administration, System Admin 110,” last revised 8/2025, stated, in part, that staff are required to follow the Eight Rights of Medication Administration, including: Right Patient; Right Medication-ensure the medication being administered matches the prescribed medication; Right Dose-ensure the dosage matches the prescribed dose; Right Route; Right Time; Right Documentation-confirm when the last dose was administered; Right Reason; and Right Response. Review of the medical record revealed Patient ID #3 was transferred to the hospital on 6/26/2026 from another acute care hospital for treatment of left lower extremity pain. Review of a Significant Event Note, dated 6/25/2026 at 5:35 PM, completed by the hospitalist physician (Employee U), revealed that while completing the patient’s discharge paperwork it was discovered that Patient ID #3 had received Methadone 180 mg at 5:05 AM on 6/25/2026 by Employee S and then received a second dose of Methadone 180 mg at 8:26 AM by Employee O. During a surveyor interview conducted on 7/1/2026 at 11:30 AM, the Director of Pharmacy Quality and Safety (Employee M) and the Manager of Inpatient Pharmacy (Employee N) stated the medication error had been investigated. Employee M explained that nursing staff may make a one-time adjustment to a medication administration time with physician approval. Any subsequent changes to scheduled administration times must be completed by the pharmacy in accordance with hospital policy so the Medication Administration Record (MAR) is updated appropriately. The pharmacy review of the MAR history determined that on 6/25/2026 Patient ID #3 received the scheduled daily Methadone dose of 180 mg at approximately 5:30 AM from Employee S. At the time of administration, the electronic MAR generated an alert indicating the medication was being administered too soon. Employee S acknowledged the alert and proceeded with medication administration. Pharmacy also determined Employee S incorrectly documented the medication administration time on the MAR. Evidence of the alert was provided during the survey. The pharmacy review further revealed that a second dose of Methadone 180 mg was administered at approximately 8:30 AM on 6/25/2026 by Employee O. Pharmacy records demonstrated that the electronic MAR generated another alert notifying the nurse that the medication was being administered too soon and displayed the previous administration date and time. Employee O proceeded with administration without responding appropriately to the warning, resulting in a duplicate dose. Employee M and Employee N acknowledged that the patient’s scheduled Methadone administration time had been changed on 6/23/2026, 6/24/2026, and 6/25/2026. They confirmed that following the initial administration time adjustment on 6/23/2026, pharmacy should have been notified to permanently adjust the scheduled administration time in the MAR in accordance with hospital policy. During a surveyor interview on 7/1/2026, Employee O confirmed she was assigned to Patient ID #3 on 6/25/2026 during the 7:00 AM to 7:00 PM shift and was working with Student Nurse Intern (SNI) Employee P for the first time. Employee O stated that she logged into the MAR and positioned the medication administration screen in front of the SNI while she remained at the patient’s bedside. She stated she heard Employee P scanning the medications, after which she scanned the patient’s identification band and administered the medications. Employee O stated that later in the shift the hospitalist (Employee R) notified her that Patient ID #3 had received Methadone 180 mg twice that morning, once at approximately 5:30 AM and again at approximately 8:30 AM. Employee O stated she asked Employee P whether any electronic alert appeared while scanning the Methadone. Employee P reported she did not observe an alert. Employee O acknowledged she failed to directly observe the SNI during medication scanning and stated she should have remained beside the SNI throughout the medication scanning process. During a surveyor interview on 7/1/2026 at 1:30 PM, the unit Clinical Manager, (Employee Q) stated that Student Nurse Interns work under the direct supervision of a registered nurse. He confirmed SNIs are not permitted to administer medications and do not possess medication administration documentation privileges. He stated registered nurses are responsible for medication administration and supervision of student interns. Employee Q stated he was unaware during the initial investigation that the SNI had independently scanned the patient’s Methadone without direct RN observation. During a surveyor interview on 7/2/2026 at 7:30 AM, Employee S confirmed administering Methadone 180 mg to Patient ID #3 at approximately 5:30 AM on 6/25/2026. Employee S stated she had completed orientation on 6/22/2026. She acknowledged administering the medication earlier than the scheduled administration time without formally changing the medication schedule. She stated she could not recall previously changing medication administration times and reported her orientation included completion of a self-directed medication documentation training packet. Employee S further acknowledged she was unaware she had documented the Methadone administration time incorrectly in the MAR. During a surveyor interview on 7/2/2026, Student Nurse Intern Employee P stated she was assigned to work with Employee O on 6/25/2026. Employee P stated she stood at the computer while Employee O remained at the patient’s bedside. She believed the RN wanted her to begin scanning the medications that were to be administered. After completing the scanning process, she waited at the computer while Employee O returned, completed the electronic documentation, and administered the medications. Employee P stated that later in the day Employee O asked whether she had observed an alert while scanning the Methadone, and she replied that she had not. Employee P stated she was familiar with electronic medication alerts and understood they require acknowledgment when displayed. She acknowledged she should not have participated in medication scanning because she did not have medication administration or documentation privileges. Employee P was shown the pharmacy audit report, which verified that while scanning the Methadone, the electronic system displayed an alert indicating the medication might be administered too soon and identified the previous administration time of approximately 5:30 AM. These findings demonstrated the hospital failed to follow its medication administration policy by failing to ensure adherence to the rights of medication administration, appropriately respond to electronic medication safety alerts, ensure pharmacy adjustment of repeated medication schedule changes, and maintain appropriate registered nurse supervision during medication administration, resulting in Patient ID #3 receiving a duplicate dose of Methadone 180 mg on 6/25/2026.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43881 Based on a review of hospital policies, medical records, staff interviews, and video surveillance footage, the hospital failed to adhere to the requirements of 482.13 Patient’s Rights after the following was identified: The hospital failed to ensure that patients received care in a safe setting after a Registered Nurse and a Security Officer failed to report suspected abuse to leadership staff. It was determined that a Registered Nurse received a verbal report from a Security Officer alleging that a patient’s fall occurred after being pushed by a Certified Nursing Assistant, resulting in the patient sustaining a scalp contusion (an injury to the bone caused by blunt impact where the skin remains unbroken). Despite the reported allegation, the Certified Nursing Assistant remained on duty until the end of the shift following the incident, (A-0144). The hospital failed to ensure staff adhered to hospital policy related to constant observation assignments (A-0144).”

“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: 43881 Based on a review of hospital policies, medical records, staff interviews, and video surveillance footage, the hospital failed to ensure that patients received care in a safe setting after a Registered Nurse (Employee C) and a Security Officer (Employee B)failed to report suspected abuse to leadership staff. It was determined that a Registered Nurse received a verbal report from a Security Officer alleging that a patient’s fall occurred after being pushed by a Certified Nursing Assistant (Employee A), resulting in the patient sustaining a scalp contusion (an injury to the bone caused by blunt impact where the skin remains unbroken). Despite the reported allegation, the Certified Nursing Assistant remained on duty until the end of the shift following the incident, creating the potential for ongoing risk to Patient ID #1 and other patients on the unit, for 1 of 3 patients reviewed for abuse. Additionally, the hospital failed to ensure that staff adhered to hospital policy regarding constant observation assignments for a patient with a physician’s order for 2:1 constant observation (Patient ID #2). Findings are as follows: 1. According to the hospital’s policy titled, “Staff Responsibility for Safety” effective 8/2019, which applies to employees as well as contract staff, “The expectation is that all staff will adhere to our culture of patients safety and report known safety events in a timely manner and with respectful communication to ensure the safest healthcare environment for our patients.” The hospital’s policy titled, “Event Reporting System, Management and Analysis” effective 10/2025, defines a “Safety Event” as “any situation or set of circumstances that harmed a patient, could lead to patient harm, is inconsistent with the routine care of a patient, and/or is inconsistent with the routine operation of the hospital ...” Further, this policy states that “Events that have caused serious harm or a condition that could cause serious harm if not prevented or remediated promptly require immediate notification and action...” The hospital’s policy titled, “Abuse of a Patient in a Healthcare Facility” effective 3/2026 states in part, “If the abuse, neglect, or mistreatment of the patient is alleged to have occurred ...immediately notify Risk Management or page the Risk Manager on call...” Additionally, abuse training for security personnel specific to “Identifying Abuse in Hospital Setting” indicates that it is the responsibility of the Security Officer to notify their supervisor as well as the patient’s nurse, charge nurse or nursing supervisor if there are concerns about a staff member harming or abusing a patient. The hospital reported to the Rhode Island Department of Health that on 6/6/2026 a CNA assigned as a 1:1 observer for a 61-year-old patient with a past medical history of borderline personality disorder, was redirecting the patient back to his/her room. According to the report, the patient believed the CNA was an intruder in his/her home, attempted to close the door, and pushed the CNA away from the doorway. In response, the CNA placed his hands on the patient’s shoulders while redirecting him/her. The report indicated that during the interaction, the patient fell and sustained a small contusion to the back of his/her head. Record review revealed that Patient ID #1, a 61-year-old person, presented to the emergency department in May of 2026 for an evaluation of mania and psychosis. Record review revealed a nursing progress note titled, “Significant Event type: Fall” dated 6/6/2026 at 1:16 AM authored by Employee C, Registered Nurse. The progress note stated that at approximately 12:56 AM, staff heard a loud noise coming from the patient’s room and upon responding, the patient was found on the floor. The nurse indicated that the staff member assigned as the patient’s 1:1 sitter (Employee A), and a Security Officer (Employee B) reported that the patient had fallen and struck his/her head on the floor. Further review revealed that the nurse noted a tender area of swelling on the patient’s head, but she was not sure whether the swelling was a result of the fall and notified the on-call physician. The nurse further indicated that the Security Officer (Employee B) who witnessed the incident reported that the patient was attempting to leave his/her room and pushed the sitter (Employee A) and the sitter then “gently pushed the patient back, after which the patient fell to the floor.” Record review revealed that the patient underwent diagnostic imaging of their head and brain which revealed a contusion on their scalp. Further record review revealed that on 6/9/2026, Patient ID #1 stated to a Social Worker, Employee D, “that tall guy pushed me...” and proceeded to show Employee D a bump on his/her head. On 6/9/2026 at 12:43 PM, recorded video footage of the incident was reviewed. The footage revealed that on 6/6/2026 at approximately 12:55 AM, Patient ID #1 was standing in the doorway of his/her room with Employee A, CNA, positioned directly in front of him/her and Employee B, Security Officer, standing nearby. The video shows the patient pushing Employee A. In response, Employee A appears to lunge toward the patient grasping him/her by the shoulders and/or upper arms and push him/her into his/her room. The patient is observed moving backwards into his/her room as Employee A pushes him/her and both individuals enter the room and move away from the camera’s view. During a surveyor interview on 6/11/2026 at 8:00 am with Employee B, Security Officer, he stated that on 6/6/2026 at approximately 1:00 AM, the patient attempted to leave his/her room and began shoving Employee A assigned as his/her 1:1 observer. Employee reported that Employee A then “lifted his hands and walked towards the patient.” Employee B stated that as the patient was walking backward, she/he tripped, fell, and struck his/her head on the floor “hard.” He noted that the patient was barefoot at the time and described the patient as “not a stable walker.” During a surveyor interview on 6/11/2026 at 9:27 AM with Employee C, RN, she stated that during the overnight night shift, she heard a loud noise and immediately responded to the patient’s room, where she found the patient on the floor. She assessed the patient and observed swelling on the patient’s head but stated that she was unsure whether the swelling was a result of the fall but indicated that the swelling was concerning. The nurse stated that she had asked Employee A and Employee B what had occurred and was only told that the patient had fallen. Employee C then stated that later on in the shift, Employee B approached her and reported that the patient had pushed Employee A and that Employee A had “pushed [him/her] back and [she/he] fell.” Employee C was asked if she had notified a Nursing Supervisor or a Clinical Manager regarding the information she received from Employee B, she responded that she submitted a report to the hospital’s internal reporting system. During a surveyor interview on 6/10/2026 at 2:35 PM and on 6/11/2026 at 10:44 AM with the Clinical Manager of Jane Brown 5 South, Employee E, she confirmed that Employee A completed his shift on 6/6/2026 at 7:30 AM. Employee E indicated that on 6/9/2026, she reviewed the video of the incident and confirmed that she had not spoken directly with Employee A. When asked to describe what she observed on the video, she stated that she saw the patient standing in the doorway of his/her room, with Employee A positioned in the doorway and Employee B standing nearby. She observed Employee A moving back and forth, swaying, and pointing in the direction of the patient’s room. She then observed the patient push Employee A, after which Employee A moved toward the patient and the patient moved backwards and then observed Employee A back out of the room. When asked what she would expect staff to do when they are informed that a staff member had pushed a patient, she stated that if she were on-site, she would expect staff to notify her immediately. If she were unavailable, she would expect staff to contact the Nursing Supervisor. When asked whether Employee A’s actions depicted in the video were appropriate and consistent with her expectations for staff conduct, the Clinical Manager stated that she was “mortified” after viewing the video and indicated that this type of behavior would be cause for termination. During a surveyor interview on 6/18/2026 at 11:47 AM with the Manager of Security (Security Services), Employee F, he stated that Employee B should have reported his concerns to a Security Supervisor and that disciplinary action would be taken because Employee B failed to report those concerns. During a surveyor interview on 6/11/2026 with the Risk Manager, no evidence was provided that Risk Management was immediately notified of the incident after it occurred per hospital policy as the nurse who was made aware of the incident did not notify a Nursing Supervisor or the Clinical Manager. 2. The hospital’s policy titled observation levels effective 12/20/2025 describes constant observation (1:1) as “the most restrictive level of observation utilized when a patient is at serious risk of harm to self or others...requiring 1:1 staff to patient ratio ...” Additionally, the hospital’s “Constant Observation Responsibilities Adult Inpatient Behavioral Health Units” form states in part, “...Remain within arm’s length distance, which may require you to sit or stand in the patient’s room with an unobstructed view of the patient...” Record review revealed that Patient ID #2, a 63-year-old patient, was transferred to the hospital in May of 2026 from another hospital where she/he had been admitted to the Behavioral Health Unit for hypersexualized behaviors and mania. According to the patient’s record, she/he had been scratching, grabbing, kicking, and spitting at staff who had difficulty redirecting him/her often resulting in the use of restraints. The patient’s level of observation was subsequently increased from 1:1 constant observation to 2:1 constant observation for safety per physician orders. Review of recorded video footage on 6/18/2026 at 10:30 AM with Employee J, Manager of Security, revealed that on 6/3/2026 at approximately 12:50 PM, Employee K, CNA, was observed sitting in a chair positioned directly in the doorway of the patient’s room. Another staff member, Employee L, CNA, was observed sitting outside the patient’s room facing the hallway and/or wall, holding a covered cup in his hands and intermittently drinking from it. Employee K was observed getting up from the chair multiple times and entering the patient’s room. She was also observed standing in the doorway with both arms raised and moving her hands in a manner consistent with protective or defensive positioning; however, the video does not clearly show the patient making contact or striking her. The footage revealed that Employee L remained seated during this period and intermittently stood to look into the room but did not enter or provide physical assistance. During a surveyor interview on 6/18/2026 at 10:39 AM with Employee M, Nursing Professional Development Manager, he reported that on the day of the incident, he was in his office, which is located down the hallway, when he heard commotion on the unit. He went to the area and was outside the patient’s room when he observed the patient interacting with staff. He stated that the patient was sitting on the floor “swatting away” at staff. He then observed Employee K’s leg “cock back and kick the patient.” He confirmed that Employee L was positioned outside of the room and indicated that both staff members should have had eyes on the patient given the ongoing situation. During a surveyor interview on 6/18/2026 at approximately 11:00 AM with the Clinical Manager, Employee E, she was asked about the expectation for staff performing 2:1 constant observation, she stated that two staff members are assigned and that “all four eyes” are to be on the patient at all times and acknowledged that she did not observe Employee L adhering to this expectation in the video. She explained that the patient’s observation status was changed to 2:1 constant observation due to the patient’s behavior, inability to be verbally redirected, and combative behavior toward multiple staff. 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 a review of hospital policies, clinical record review, and staff interviews, the hospital failed to ensure that patients’ intravenous access site dressings were changed, dated, and removed in accordance with hospital policy (A-0398). Additionally, the hospital failed to ensure that emergency department personnel adhered to hospital guidelines and policies related to obtaining vital signs and assessing and reassessing pain (A-0398).”

“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 a review of hospital policies, clinical records, and staff interviews, the hospital failed to ensure that the use of violent restraints was in accordance with the order of a physician responsible for the care of patients for 2 of 4 patients reviewed for violent restraints (Patient ID #s 1 and 2). Findings are as follows: The hospital’s policy titled, “Patient Restraint and Seclusion” last revised 3/2026 defines “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.” 1. Clinical record review revealed that Patient ID #1 presented to the Emergency Department in April of 2026 due to altered mental status. At approximately 5:45 AM on 4/29/2026, Patient ID #1 began to hit, kick, and scratch staff. Staff attempted to deescalate the patient, but attempts were unsuccessful, and the patient refused to cooperate, ultimately requiring the application of violent restraints. The clinical record indicated that at 6:00 AM, Patient ID #1 was restrained by his/her left wrist, right and left biceps, and right and left ankles. According to Patient ID #1’s clinical record, the physician’s order for the application of violent restraints instructed staff to restrain the patient by both wrists and both lower extremities. However, the physician’s order did not include instructions to restrain the patient’s biceps. 2. Clinical record review revealed that Patient ID #2 presented to the Emergency Department in December of 2025 due to alcohol intoxication. The clinical record indicated that while being transported to the psychiatric unit of the Emergency Department, Patient ID #2 became agitated, jumped off the stretcher and attempted to strike security personnel. Patient ID #2 was then handcuffed by a police officer and placed back onto the stretcher. Patient ID #2 was subsequently restrained at 5:25 AM by both wrists, both biceps, and both ankles. According to Patient ID #2’s clinical record, the physician’s order for the application of violent restraints instructed staff to restrain the patient by both wrists and both lower extremities. However, the physician’s order did not include instructions to restrain the patient’s biceps. During a surveyor interview on 4/30/2026 at 2:14 PM with the Vice President/Chief Nursing Officer, Employee D, she acknowledged that physician orders for violent restraints for both patients were inconsistent with what was initially applied and further indicated that ordering providers have the option to select additional limbs including the biceps. 45769”

“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 a review of hospital policies, clinical records, and staff interviews, the hospital failed to ensure that the condition of the restrained patient was monitored by trained staff in accordance with hospital policy for 1 of 4 patients reviewed, (Patient ID #3). Findings are as follows: The hospital’s policy titled, “Patient Restraint and Seclusion” last revised 3/2026 defines a violent medication restraint as “the use of medication [for] behavior that is not a standard of treatment or dosage for the patient’s condition or symptoms, with the intent of controlling behavior by restricting movement.” The policy further states that for violent restraints including physical holds, mechanical restraints, escorts, and seclusion, the Registered Nurse is to assess the patient at the initiation of the restraint and every 15 minutes thereafter. For a violent medication restraint, the policy states that the Registered Nurse is to assess the patient at the initiation of the restraint and every 15 minutes thereafter for a minimum of one hour. Additionally, the policy indicates that for both violent restraints and violent medication restraints, the assessment includes but is not limited to the following: - Psychological status/patient response - Physical comfort - Skin integrity, circulation, sensation and movement Clinical record review revealed that Patient ID #3 presented to the Emergency Department in April of 2026 due to alcohol intoxication. The clinical record indicated that according to the Emergency Department Resident Physician the patient was agitated and combative and due to the patient’s escalating agitation and danger to himself/herself and others, she/he required the use of chemical sedation which was achieved with droperidol (a medication used as a sedative, or to prevent nausea and vomiting) and versed (a medication used as a sedative and to reduce anxiety) and physical restraints after attempts to de-escalate the patient were unsuccessful. According to the patient’s clinical record, a physician’s order for the application of violent restraints was entered into the record at 11:35 PM on 4/29/2026 with instructions to restrain the patient by both wrists, both biceps, and both lower extremities (6-point restraints). The restraints were then discontinued by 11:58 PM. The patient’s clinical record failed to reveal evidence that a Registered Nurse documented the required violent restraint assessment specific to the 6-point restraints applied at the initiation of physical restraints and after 15 minutes. Additionally, the record failed to reveal evidence that a Registered Nurse documented the required violent medication restraint assessment at the initiation and every 15 minutes thereafter for a minimum of one hour. During a surveyor interview on 4/30/2026 at 2:14 PM with the Vice President/Chief Nursing Officer, Employee D, she acknowledged the nursing assessments specific to both physical and chemical restraints were not documented by a Registered Nurse in the clinical record in accordance with hospital policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 43881 Based on a review of hospital policies, clinical records, and staff interviews, the hospital failed to ensure that a patient was seen face-to-face within one hour after the initiation of violent restraints in accordance with hospital policy for 1 of 4 patients reviewed, (Patient ID #1). Findings are as follows: The hospital’s policy titled, “Patient Restraint and Seclusion” last revised 3/2026 states in part that for violent restraints the provider performs a face-to-face assessment within 1 hour of the initiation. Clinical record review revealed that Patient ID #1 presented to the Emergency Department in April of 2026 due to altered mental status. At approximately 5:45 AM on 4/29/2026, Patient ID #1 began to hit, kick, and scratch staff. Staff attempted to deescalate the patient, but attempts were unsuccessful, and the patient refused to cooperate, ultimately requiring the application of violent restraints. The clinical record indicated that at 6:00 AM, the patient was restrained by his/her left wrist, right and left biceps, and right and left ankles. According to the clinical record, the patient was not evaluated face-to-face within one hour in accordance with hospital policy until a physician arrived at the patient’s bedside at 8:49 AM, two hours and forty-nine minutes later. During a surveyor interview on 4/30/2026 at 2:14 PM with the Vice President/Chief Nursing Officer, Employee D, she confirmed that it is the hospital’s practice to perform a face-to-face evaluation within one hour following the application of violent restraints. 45769”

“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 46539 Based on a review of hospital policies, record review, and staff interviews, the hospital failed to ensure that patients’ intravenous access site dressings were changed, dated, and removed in accordance with hospital policy for 6 of 7 patients reviewed, (Patient ID #s 4, 5, 6, 7, 8, and 9). Additionally, the hospital failed to ensure that emergency department personnel adhered to hospital guidelines and policies related to obtaining vital signs for 3 of 5 patients (ID #s 10,11, and 12), and reassessing pain for 2 of 5 patients (ID #s 10 and 12). Findings are as follows: 1. The Hospital’s policy titled, “Peripheral Intravenous Access [PIV] (IV) Insertion, Flushes, Assessment, Dressings, and Removal” states in part, “in adult settings, PIVs and extended dwell IVs with no signs or symptoms of complications...should be replaced every 96 hours...” “All PIVs and extended dwell IVs should be removed prior to discharge. Removal will be documented with removal reason of ‘discharged’.” “...Dressings a. All PIV and extended dwell IV site: i.A hospital-approved transparent dressing will be used. ii.The dressing must be labeled with the date of insertion, and the initials of the RN [registered nurse] who performed the insertion. When a dressing is changed, the RN who changes the dressing will label the dressing with the original insertion date, and the date of dressing change...” 1a. Review of a community reported allegation submitted to the Rhode Island Department of Health on 4/24/2026, alleged that Patient ID #4, was discharged home from the hospital with his/her PIV still inserted in his/her right arm. Attached to the allegation, was a photograph of a patient’s arm with an IV dated 4/12. Clinical record review revealed that Patient ID #4 was admitted to the hospital due to a syncopal episode. Review of the documentation for Patient ID #4 revealed a PIV was inserted on 4/13/2026 with a date for the PIV to be changed on 4/17/2026. Further review of the documentation failed to reveal evidence that the PIV was changed after 96 hours (4 days), in accordance with the hospital policy, and was in place for approximately 9 days. Additionally, the record failed to reveal evidence that the PIV was removed at discharge. On 4/22/2026 at 12:21 PM, the hospital documented that the home care agency for Patient ID #4, would go to the patient’s house on 4/22/2026 to remove the PIV. During a surveyor interview on 4/28/2026 at 12:32 PM, with RN Staff E, she acknowledged that Patient ID #4 was discharged home with his/her PIV and stated that it was “an oversight.” During a surveyor interview on 4/28/2026 at 11:17 AM, with the Clinical Manager of Cooperative Care Center 3, Staff F, he confirmed that the PIV should have been changed and removed prior to discharge in accordance with hospital policy. 1b. Clinical record review revealed that Patient ID #6 was admitted to the hospital due peripheral vascular disease. During a surveyor observation with Staff F on 4/29/2026 at 10:11 AM of Patient ID #6, revealed his/her PIV with a date of 4/16/2026. During a surveyor interview immediately following the above-mentioned observation, Staff F acknowledged that Patient ID #6’s PIV was dated 4/16/2026, indicating that the PIV had been in place for approximately 13 days, and acknowledged that the PIV was not replaced in accordance with hospital policy. 1c. Clinical record review revealed that Patient ID #9 was admitted to the hospital due to a motorcycle collision. During the medication administration observation on 4/29/2026 at 10:00 AM with RN Staff G, it revealed that Patient ID #9 had two PIVs, one in the right hand and one in the right forearm. Both PIVs were undated. During a surveyor interview immediately following the above-mentioned observation, Staff G acknowledged that both of the PIVs were not labeled with the date of insertions and the initials of the RN who performed the insertions according to the hospital’s policy. 1d. Clinical record review revealed that Patient ID #8 was admitted to the hospital due to abdominal pain. During the medication administration observation on 4/30/2026 at 8:34 AM with RN Staff H, it revealed that Patient ID #8 had one PIV in his/her left forearm that was undated. During a surveyor interview immediately following the above-mentioned observation, Staff H acknowledged that the PIV was not labeled with the date of insertion, and the initials of the RN who performed the insertion, according to the hospital’s policy. 1e. Clinical record review revealed that Patient ID #7 was admitted to the hospital following a Motorcycle Crash. During the medication administration observation on 4/29/2026 at 10:21 AM, with RN Staff I, it revealed that Patient ID #7 had one PIV in his/her left forearm and one PIV in the right upper arm, both were undated. During a surveyor interview immediately following the above-mentioned observation, Staff I acknowledged that both of the PIVs were not labeled with the dates of insertion, and the initials of the RN who performed the insertions, according to the hospital’s policy. 1f. Clinical record review revealed that Patient ID #5 was admitted to the hospital due to major neurocognitive disorder. Record review revealed that Patient ID #5 had a PIV placed on 3/27/2026 with a due date to be changed on 3/31/2026. Further review revealed that the PIV was not replaced every 96 hours (4 days) in accordance with the hospital’s policy and was in place for a total of 6 days. During a surveyor interview on 4/30/2026 at approximately 1:30 PM, with Staff J, Regulatory Readiness Specialist, she was unable to provide evidence that Patient ID #5’s PIV was replaced in accordance with the hopsital’s policy. 2. Review of the hospital’s policy titled, “Emergency Department Patient Assessment, Vital sign Management, and Reassessment Policy” last revised 10/2025 states in part, “...Vital signs: Includes pulse rate, respiration rate, blood pressure, temperature, oxygen saturation, and pain assessment... ...ESI (Emergency Severity Index) 2 = Documented reassessments every 1 hour until hemodynamically stable, then minimally every 4 hours... ...Vital signs are also repeated when: ...Clinically indicated ...Before and within one hour after the administration of pain medication...” 2a. Record review revealed that the following patients’ vital signs were not completed per hospital policy for ESI 2: Patient ID #10 vital signs were not obtained again until 11:00 PM, 3 hours and 35 minutes after their initial triage vital signs were obtained on 4/14/2026 at 7:25 PM. The patient experienced a change in condition and was transferred into a Critical Care Room at 10:32 PM. Patient ID #11 vital signs were not obtained again unitil 4:40 AM, approximately 4 hours and 40 minutes after their vital signs were obtained on 4/15/2026 at 12:08 AM. During a surveyor interview on 4/27/2026 at 3:15 PM with the Emergency Department Clinical Manager, Employee A, he acknowledged that the above vital signs were not being obtained per the hospital’s policy. 2b. Record review for Patient ID # 10 revealed she/he presented to the Emergency Department in April of 2026 at 7:06 PM complaining of shortness of breath and generalized weakness. At 7:25 PM the patient endorsed 10 out of 10 severe pain as recorded by the emergency room technician. The record failed to reveal a pain assessment by a registered nurse, or documentation of the location or description of the pain. The record failed to reveal evidence that a Registered Nurse or a provider was notified of the patient’s severe pain.The record contained an order for oxycodone (a medication used to treat pain) that was placed at 9:31 PM and was never administered. At 10:00 PM the medical record revealed that during the physician’s medical screening exam the patient was described as “very uncomfortable and writhing in bed.” At 11:00 PM the patient’s vital sign assessment failed to include a pain assessment. Further record review revealed that Patient ID #10 did not receive pain medication until 11:10 PM on that date. During a surveyor interview and patient record review on 04/30/2026 at approximately 1:30 PM with Employee B, the Emergency Department Quality and Safety Manager, she was unable to provide evidence that a pain assessment was completed by a registered nurse after Patient ID #10 reported 10 out of 10 pain to the Emergency Room Technician. 2c. Record review revealed that Patient ID #12, who has a medical history of migraines, presented to the Emergency Department in December of 2025 at 5:31 AM. At 5:32 AM, vital signs were obtained revealing a temperature of 96.6 degrees Fahrenheit. At this time, the patient denied feeling pain. Record review of a nursing triage note recorded at 5:32 AM indicated that the patient reported feeling extremity numbness and a migraine that awakened him/her from sleep. The patient was noted to be cool, with stiff extremities but were equal in strength and sensation, and with pupils equal, round, and reactive to light, with no droop or drift. The patient indicated at this time that his/her symptoms were improving. At 6:27 AM, Employee C, Licensed Practical Nurse, indicated in a note that the patient reported 10/10 pain and stated that he/she felt as though he/she might pass out. The patient requested pain medication and was offered an ice pack for comfort. However, there was no documented evidence that vital signs or a reassessment were performed at that time despite the patient’s report of severe pain and feeling faint. According to the record, a physician did not evaluate the patient until 7:29 AM, more than one hour after the patient reported worsening symptoms. At that time, the physician documented that the patient appeared “uncomfortable” and “diffusely tremulous.” At 7:40 AM, nursing staff documented that the patient described the headache as “unlike anything [he/she] has ever had in [his/her] life,” and reported nausea, dizziness, blurry vision, and photosensitivity, stating, “I feel like I could just die.” The patient was then activated as a code stroke and transported for diagnostic imaging. Record review of provider notes revealed that the patient had “questionable mild dysmetria” of the right arm “with possible subtle weakness.” The pupils were reactive but unequal, measuring 2 millimeters on the right and 3 millimeters on the left. During a surveyor interview on 4/28/2026 at 2:53 PM, the Clinical Manager of the Emergency Department, Employee A, acknowledged that the patient’s complaint at 6:27 AM of severe pain and feeling as though she/he was going to “pass out” represented a change from the initial triage presentation. He confirmed that the nurse who documented the patient’s condition was a Licensed Practical Nurse (LPN) and indicated that he would expect a change in patient condition, including reports of severe pain and request of pain medication, to be escalated to a provider. He also acknowledged that the medical record did not demonstrate that the LPN, Employee C, obtained vital signs or notified a provider of the patient’s report of severe pain, request for pain medications, and feeling as though she/he might “pass out.””

“RADIOLOGIC SERVICES CFR(s): 482.26 The hospital must maintain, or have available, diagnostic radiological services. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications. This Condition is not met as evidenced by: 43881 Based on record review and staff interviews, the hospital failed to ensure that radiologic services were provided in accordance with accepted standards of practice for accurate interpretation of imaging findings for Patient ID #1 (2-year-old), who retained a foreign fragment in the right axillary vein following multiple peripherally inserted central catheter (PICC) placement attempts. Although the retained fragment was visible on five imaging studies, the radiologists who interpreted these studies failed to identify it, resulting in the fragment remaining undiagnosed for approximately six months. (A-0535).”

“SAFETY POLICY AND PROCEDURES CFR(s): 482.26(b) [§482.26 Condition of Participation: Radiologic Services §. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.] §482.26(b) Standard: Safety for Patients and Personnel The radiologic services, particularly ionizing radiology procedures, must be free from hazards for patients and personnel. This Standard is not met as evidenced by: 43881 Based on record review and staff interviews, the hospital failed to ensure that radiologic services were provided in accordance with accepted standards of practice for accurate interpretation of imaging findings for Patient ID #1 (2-year-old), who retained a foreign fragment in the right axillary vein following multiple peripherally inserted central catheter (PICC) placement attempts. Although the retained fragment was visible on five imaging studies, the radiologists who interpreted these studies failed to identify it, resulting in the fragment remaining undiagnosed for approximately six months for 1 of 1 patient who underwent multiple PICC placement attempts, (Patient ID #1). Findings are as follows: Record review of the radiologist job description states in part, “...This role involves performing and supervising imaging procedures, generating timely and accurate diagnostic reports, consulting with referring clinicians, and ensuring high standards of patient care, safety, and regulatory compliance...” Record review revealed that Patient ID #1 was transferred to the hospital’s Pediatric Intensive Care Unit from another hospital in June of 2024. On 10/2/2025, Employee A, Nurse Practitioner, attempted and failed to successfully place a PICC in the patient’s right femoral vein (a deep vein in the thigh), the right basilic vein (a vein in the upper arm), and the right cephalic vein (a vein in the upper arm) since the catheter was difficult to advance into the vessel. Employee A made a final attempt through the cephalic vein and was successful. The record indicated that a chest X-ray was obtained to confirm the placement of the PICC. Employee B, Radiologist, confirmed placement by indicating that the tip of the catheter was in the left subclavian vein (a vein beneath the collarbone). However, the report failed to identify the retained fragment in the right axillary vein. Additional imaging studies were performed for Patient ID #1 on 10/7/2025, 10/10/2025, 12/7/2025, and 12/26/2025. The results were interpreted by the following employees: On 10/7/2025, the imaging study was interpreted by Employees C and D, Radiologists. On 10/10/2025, the imaging study was interpreted by Employee B, Radiologist. On 12/7/2025, the imaging study was interpreted by Employee D, Radiologist. On 12/26/2025, the imaging study was interpreted by Employee E, Radiologist. In each instance, the retained fragment, which was visible on the imaging studies, was not identified by the interpreting radiologists. Further, the record indicated that the imaging study interpreted on 12/7/2025 was compared to the imaging study results from 10/10/2025 and the imaging study interpreted on 12/26/2025 was compared to the imaging study results from 12/7/2025. However, during the comparison review, the radiologists failed to identify the retained fragment in the right axillary vein. During a surveyor interview on 4/10/2026 at 12:35 PM with the Director of Quality and Clinical Operations of Radiology, Employee F, he confirmed that the imaging films had been reviewed retrospectively, and the retained fragment was visible on all images.”

“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: 46539 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: The hospital failed to ensure nursing staff were reeducated following the administration of an inaccurate dose of U-500 insulin (A-0398). The hospital failed to ensure nursing staff failed to complete an oral assessment and oral care in accordance with hospital protocol (A-0398). The hospital failed to ensure interpreter services were provided to a patient upon arrival to the Psychiatric Emergency Services (PES) unit during the intake process (A-0398). Findings are as follows: A Centers for Medicare/Medicaid Service (CMS) authorized Federal substantial allegation survey was conducted from 3/24/2026 through 3/30/2026 at Rhode Island Hospital 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 the hospital failed to ensure that nursing personnel confirmed their understanding of the use of a U-500 insulin pen following a U-500 insulin administration error where Employee A, Registered Nurse, transferred insulin from a U-500 insulin pen incorrectly using a U-100 insulin syringe, administering 5 times the ordered dose to Patient ID #1. As a result, Patient ID #1 was administered the incorrect insulin dose despite a second RN verification signing off, which caused the patient’s blood sugar to drop to 25 (normal range is 70-99), requiring the patient to receive additional treatment for hypoglycemia (low blood sugar). The hospital was informed of the Immediate Jeopardy and was provided with the Immediate Jeopardy template on 3/26/2026 at 11:30 AM, after it was identified. On 3/26/2026, 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. Pharmacy created an Our Practice Advisory (OPA) on Insulin U-500 pen which went into effect at 2:00 PM on 3/26/2026, creating a hard stop on every U-500 Insulin Pen ordered. 2. The U-500 Insulin Pen Safety Alert and Education was revised on 3/26/2026. 3. Effective 3/26/2026, whenever an Insulin U-500 pen is ordered the nursing staff supervisor will pick it up from the pharmacy and bring the insulin pen to the ordering unit. The supervisor will educate the nurse and act as the dual sign-off with the educated RN. 4. The hospital developed a net learning on Insulin U-500 Pen Safety Alert and Education and has assigned it to all Rhode Island Hospital nurses starting 3/27/2026. Once 100% of nurses complete the net learning, the above process involving the nursing supervisors will be concluded.”

“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 surveyor observation, record review and staff interviews, the hospital failed to ensure that nursing personnel confirmed their understanding of the use of a U-500 insulin pen following a U-500 insulin administration error where Employee A, Registered Nurse (RN), transferred insulin from a U-500 insulin pen incorrectly using a U-100 insulin syringe, administering 5 times the ordered dose to Patient ID #1. As a result, Patient ID #1 was administered the incorrect insulin dose despite a second RN verification sign-off, which caused the patient’s blood sugar to drop to 25 (normal range is 70 to 99), requiring the patient to receive additional treatment for hypoglycemia (low blood sugar). Additionally, the hospital failed to ensure interpreter services were provided to a patient upon arrival to the Psychiatric Emergency Services (PES) unit during the intake process and, as a result, failed to ensure staff explained the unit’s intake procedures in accordance with hospital policy for Patient ID #4. Furthermore, the hospital failed to follow the hospital protocol related to oral care for 3 of 3 patients reviewed, Patient ID #1, #2, and #3. Findings are as follows: 1. Review of a hospital reported incident submitted to the Rhode Island Department of Health on 3/9/2026, revealed that on March 4, 2026, the hospital identified that a patient was administered 50 units of insulin drawn from a U-500 insulin pen using a U-100 insulin syringe. Review of a hospital policy titled, “Safe Use Of Injectable Medications In Multi-Dose Vials, Single-Dose Vials, And Pen Devices, PH-212” last revised on 12/2025, states in part, “...Pen devices...b. Must be administered using a pen needle a. Must never withdraw a dose by puncturing the stopper with a needle/syringe...d. The pharmacy supplied pens and needles shall be stored in the patients’ tower bin...” Record review revealed that Patient ID #1 presented to the emergency room in March of 2026 with a chief complaint of generalized weakness following a fall. Review of Patient ID #1’s History and Physical dated 3/3/2026 documented that the patient takes 90 units of U-500 insulin in the morning and 80 units of U-500 insulin in the evening. Additionally, the assessment and plan revealed that the provider will change the dose of insulin to 50 units of U-500 insulin twice a day. On 3/3/2026 the physician ordered to administer 50 units of Insulin regular (HumuLIN R) CONCENTRATED injection 500 units/milliliter pen. Special instructions included to prime the pen prior to each dose, attach a new needle, rotate the selector to ordered dose, confirm display matched the medication administration record, obtain a second nurse signature, administer the pen, and refer to tip sheet link for detailed administration steps. Record review revealed that on 3/3/2026 at 8:42 PM, Patient ID #1 was administered 50 units of U-500 insulin by Employee A, RN, and co-signed and verified by Employee B, RN, indicating that two nurses reviewed the U-500 insulin medication preparation prior to the administration. Review of the emergency department timeline revealed that on 3/4/2026 at 3:31 AM the patient’s blood sugar resulted at 25. Record review of a significant event note dated 3/4/2026 at 3:31 AM, revealed that around 3:00 AM the patient felt himself/herself shivering. As a result, the patient received an intravenous bolus of 250 milliliters of D10 (a 10% dextrose solution used in medical settings to rapidly increase blood glucose levels, particularly in treating hypoglycemia), and an endocrine consult was placed to evaluate the patient in the morning. Record review of a significant event note dated 3/4/2026 at 7:29 AM, revealed that upon transfer to the inpatient medical unit, the patient was reporting weakness, shakiness and sweating and was noted to have a blood sugar of 54. As a result, the provider was made aware and a D5W infusion (Dextrose 5% in water is used to treat hypoglycemia, insulin shock, or dehydration, fluid loss) was initiated. Record review revealed an endocrinology consult was completed by Employee C on 3/4/2026 at 8:14 AM, which recommended to discontinue the U-500 insulin while inpatient and transition to U-100 insulin given the patient typically requires significantly lower insulin doses while inpatient and to also “avoid errors with medication administration.” Record review revealed a nursing progress note dated 3/5/2026 at 3:30 PM, that the incorrect dose of insulin was administered to the patient in the emergency department. On 3/25/2026 a surveyor interview was conducted with the Risk Manager at 9:47 AM. She revealed that on 3/5/2026 a meeting was held with Pharmacy and Risk Management and on 3/6/2026, a critical event huddle with executive leadership was held. The Risk Manager indicated that on 3/24/2026, an Apparent Cause Analysis (ACA) was conducted, and further revealed that a corrective action plan was in the progress of development. Furthermore, she revealed that she did not interview Employee B, who co-signed the insulin administration prior to the medication error, and was unable to provide evidence that coaching or re-education was provided to Employee B. Review of a document provided by the Risk Manager titled, “Action Plan Addressing Root Causes...ACA Action Plan)” revealed that as a result of the ACA, it was determined that the corrective action plan would include the following: 1. Hard stop to the U-500 insulin 2. Redistribution of the original U-500 insulin education to all Emergency Department staff 3. Asses level of knowledge and agreement around meaning of dual RN sign-off However, the plan of action was incomplete. During a surveyor interview on 3/25/2026 at 1:00 PM with the Director of Pharmacy and Patient Safety, Employee E, and Director of Inpatient Pharmacy, Employee F, they explained the hospital recently implemented the use of U-500 insulin pens to replace the multidose vials of U-500 insulin. They further revealed that Patient ID #1 was the first patient to receive U-500 insulin since this change. Employee E indicated that during a review of hypoglycemia events, Patient ID #1 was reviewed on 3/4/2026. It was identified that Employee A removed the patient’s U-500 insulin from the pen using a U-100 insulin syringe. They further acknowledged that the U-500 insulin pen was sent to the unit without the required needle. Review of document titled “3.16.26 Huddle Talking Points” revealed the following information related to the U-500 insulin was discussed in the emergency room after the medication error, “The U-500 Kwikpen is a high concentrated insulin. Do not transfer Humulin R U-500 insulin from Kwickpen delivery system into a syringe. If a Kwickpen needle is not present in the Omnicell with the Kwickpen delivery system contact pharmacy.” Additionally, an email was sent to the staff in the emergency room staff on 3/16/2026 which revealed the following, “Medication Safety Reminder - U-500 KwikPen ...Humulin R U-500 is a highly concentrated insulin. Do not transfer insulin from the KwikPen into a syringe. If KwikPen needles are not available in the Omnicell with the KwikPen, please contact pharmacy.” During a surveyor interview on 3/25/2026 at 2:12 PM, with Regulatory Specialist, Employee G, she revealed that per the Chief Nursing Executive, a shift huddle was conducted after the event but there is no documentation of which nurses or how many nurses attended the huddle or received the education, indicating that the hospital is unaware of how many nurses and which nurses received the reeducation related to the change in the U-500 insulin delivery system. During a surveyor interview with Employee B, on 3/26/2026 at 2:29 PM, he revealed that he reviewed the syringe that Employee A prepared for administration but that he was not aware that the medication was U-500 insulin and was only confirming that the units in the syringe matched the ordered number of units. He acknowledged that he did not review the label on the insulin pen and did not follow the verification workflow for the administration of insulin. Additionally, he revealed that prior to the initiation of the pens, the hospital sent out an email that was just a notification that the pens were coming and did not go into details of the pen. During a surveyor interview with Employee A, on 3/27/2026 at 5:00 PM, she revealed that she was not aware that the U-500 insulin pen and the U-100 syringe were different concentrations. She revealed that she did not receive education from the hospital related to the initiation of the U-500 insulin pens. Additionally, she revealed there were no needles provided with the insulin pen. During a surveyor interview on 3/25/2026 at 2:38 PM with the System Director of Education, Employee I, she revealed that a newsletter was sent out in February of 2026 to all staff and a power point was sent to all Clinical Managers, who were responsible for communicating the education to their staff. She revealed that this education was not added into the hospital online learning database for all staff to complete. Additionally, she was unable to provide evidence of how many nurses received the education or reeducation related to the change in the U-500 insulin delivery system. During a surveyor interview with the Clinical Manager of the Emergency Department, Employee J, on 3/25/2026 at 2:38 PM, he revealed that the emergency department did not have a staff meeting in February, but they did have one in March. Furthermore, he revealed that this meeting was not heavily focused on the change in the insulin delivery system or the pen, and no sign-in sheet is usually completed with any staff meetings. During the interview, the surveyor provided Employee J with the “insulin U-500 Pen Conversion” education. He confirmed that this was the first time he was reviewing the education and “never used an insulin pen.” During a surveyor interview on 3/26/2026 at approximately 9:00 AM, with the Educators and Coordinators of the Emergency Medical Services for Rhode Island and Hasbro Children Hospital, Employees K and L, they confirmed that there was no evidence of education provided to the staff prior to the implementation of the U-500 insulin pen on 2/24/2026. Additionally, they were unable to provide evidence of who received the reeducation following the U-500 insulin medication error. 2. According to the hospital’s policy titled, “Psychiatric Emergency Services (PES), Emergency Department” effective 10/2025 states in part, “The Psychiatric Emergency Services (PES) unit at Rhode Island Hospital is a specialty unit within the adult emergency department for individuals requiring a safe, supervised environment while undergoing evaluation and stabilization of their medical and psychiatric complaints... ...Upon arrival to PES all patients will be searched and changed in the Intake room... ...Search Process- Patient and Belongings... ...The PES staff are responsible for explaining the procedure to the patient...” Record review revealed that Patient ID #4 presented to the Emergency Department in March of 2026 with complaints of depression and suicidal ideation. According to the record, an interpreter was used during triage. The patient was described as tearful, with pressured speech, and stated that she/he did not want to live anymore and had thought of ways to end his/her life. The patient was subsequently transferred to the PES unit. During a surveyor observation on 3/26/2026 at 9:28 AM, Patient ID #4 was observed entering the PES intake area accompanied by staff. The patient was escorted into a room and changed from street clothes into hospital attire. A Registered Nurse, Employee M, entered the intake room while the patient was undressing. Employee M and the patient exited the room and a Security Officer, Employee N, then used a handheld metal detector to scan the patient. During the search, the Security Officer paused at the patient’s left ankle and repeated the scan. The patient asked, in their primary language, “Why is he putting this on me? What is this?” referring to the handheld metal detector. Neither the nurse nor the Security Officer responded to the patient’s questions. During a surveyor interview on 3/26/2026 at approximately 9:45 AM with Patient ID #4, she indicated that she/he did not know why she/he was in this unit and asked in his/her primary language, “Do I need to stay here? What do I do?” During a surveyor interview on 3/26/2026 at 2:37 PM with Employee O, Registered Nurse, who works in the PES unit, she indicated that interpreter services are obtained the moment a patient arrives through the door in the PES unit, especially since “it can be very frightening for someone.” She further stated that “patients have the right to know the process.” During a surveyor interview on 3/26/2026 at approximately 10:00 AM with the Associate Chief Nursing Officer and Vice President, Employee P, she was unable to provide evidence that interpreter services were utilized for Patient ID #4 during the patient search process in the PES unit and indicated that this was an opportunity for improvement. 3. Review of the hospital “Oral Care Protocol” last revised on 4/2025, revealed in part, “...Patients who have the developmental skills will be given the opportunity to perform oral care. ...RN’s will perform an oral assessment upon admission, daily, and with changes in condition for all admitted patients on a medical surgical, critical care, and inpatient rehab using the Oral Assessment Guide section of the Daily Care/Safety flowsheet in the electronic health record (EHR) a. RN’s are responsible for the oral assessment using the Oral Assessment Guide (OAG) b. RN’s may provide all levels of oral care of the approved Oral Care Protocol (OCP) c. RN’s may delegate oral care per the appropriate Oral Care Protocol...” Additionally the policy revealed that “ADULT ORAL CARE PROTOCOL (OCP TOOL)... ...Rns: perform daily OAG assessment once a day. Visualize entire oral cavity, including lips, tongue, gingiva, teeth, and mucus membranes...” Further review of the policy revealed there were multiple OCP levels with a minimum frequency of oral care two times a day. 3a. Review of a community reported allegation submitted to the Rhode Island Department of Health on 11/7/2025, alleged that Patient ID #2, did not receive assistance with oral care from the staff while in the hospital. Record review revealed that Patient ID #2 was admitted to the hospital in October of 2025 with a past medical history of spina bifida (a condition when the spine doesn’t close completely during embryonic development) and spastic quadriplegia (a condition affecting all four limbs, the trunk, and often the face, causing stiff, jerky movements and significant motor impairments). Record review revealed the patient was in the hospital for a total of 18 days. Further review failed to reveal evidence that an Oral Assessment Guide was documented daily for 16 out of 18 days according to hospital policy. Record review failed to reveal evidence that the patient was offered, refused, or was provided with oral care daily or at minimum twice a day per the protocol for 14 days. 3b. Record review revealed that Patient ID #1 was in the hospital for a total of 15 days. Further review failed to reveal evidence that an Oral Assessment Guide was documented daily for 12 out of 15 days according to hospital policy Record review failed to reveal evidence that the patient was offered, refused, or was provided with oral care daily or at minimum twice a day per the protocol for 12 days. 3c. Record review revealed that Patient ID #3 was in the hospital for a total of 28 days. Further review failed to reveal evidence that an Oral Assessment Guide was documented daily for 19 out of 28 days according to hospital policy. Record review failed to reveal evidence that the patient was offered, refused, or was provided with oral care during his/her 28 days in the hospital. During a surveyor interview on 3/27/2026 at approximately 2:00 PM, with the Risk Manager, she was unable to provide evidence that the nursing personnel followed the hospital protocol related to oral care for Patient ID #s 1, 2, and 3. 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 hospital policy review, record review and staff interviews, the hospital failed to ensure that emergency department personnel adhered to hospital guidelines and policies relative to obtaining vital signs for 9 of 19 patients (ID #s 2, 3, 4, 5, 6, 8, 12, 14, and 15), reassessing pain for 2 of 3 patients (ID #s 4 and 8), and reporting abnormal vital signs to a provider for 3 of 3 patients reviewed (ID #s 1, 2, and 8), (A-0398). Additionally, the hospital failed to ensure emergency department personnel administered medication orders timely for 2 of 7 patients reviewed for medication administration (ID #s 2 and 4), (A-0398).”

“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 hospital policy review, record review and staff interviews, the hospital failed to ensure that emergency department personnel adhered to hospital guidelines and policies relative to obtaining vital signs for 9 of 19 patients (ID #s 2, 3, 4, 5, 6, 8, 12, 14, and 15), reassessing pain for 2 of 3 patients (ID #s 4 and 8), and reporting abnormal vital signs to a provider for 3 of 3 patients reviewed (ID #s 1, 2, and 8). Additionally, the hospital failed to ensure emergency department personnel administered medication orders timely, as prescribed for 2 of 7 patients reviewed for medication administration (ID #s 2 and 4). Findings are as follows: 1. The hospital’s policy titled, “Vital Sign Measurement Guideline, Emergency Department” last revised 9/2025 states in part, “All patients should have vital signs (pulse, blood pressure, respirations, temperature, pulse oximetry and pain level) as soon as possible on arrival to the emergency department. Repeat Vital signs will be performed: 1. Every 2 hours in non-critical areas... 2. Every 2 hours at triage areas...” ...Abnormal vital signs are reported to the Registered Nurse (RN)...” Record review revealed that the following patients’ vital signs were not completed every two hours per hospital guidelines: Patient ID #2’s vital signs were obtained 4 hours and 4 minutes after their initial triage vital signs were obtained on 11/4/2025 at 2:13 AM. Patient ID # 3’s vital signs were obtained 3 hours and 5 minutes after their initial triage vital signs were obtained on 11/4/2025 at 12:14 PM. Patient ID #4’s vital signs were obtained 4 hours and 31 minutes after their initial triage vital signs were obtained on 11/4/2025 at 9:50 AM. Patient ID #5’s vital signs were obtained 3 hours and 4 minutes after their initial triage vital signs were obtained on 10/31/2025 at 3:49 AM. Patient ID #6’s vital signs were initially obtained at 10:43 AM on 10/31/2025. At 2:45 PM, approximately 4 hours later, the patient was called to have vital signs obtained, but it was then determined that the patient had left the Emergency Department without being seen. Patient ID # 8’s vital signs were obtained 5 hours and 22 minutes after their initial triage vital signs were obtained on 10/31/2025 at 9:05 AM. Patient ID #12’s vital signs were obtained on 11/4/2025 at 1:55 PM and were not obtained until 3 hours and 39 minutes later. Patient ID #14’s vital signs were obtained 4 hours and 7 minutes after they were last obtained on 11/3/2025 at 8:04 PM. Patient ID #15’s vital signs were obtained 2 hours and 40 minutes after their initial triage vital signs were obtained on 10/30/2025 at 10:46 AM. During a surveyor interview on 11/5/2025 at 3:15 PM with the Emergency Department Nursing Director, Employee A, she acknowledged that not all patients’ vital signs are being obtained every two hours as per the hospital policy. 2. The hospital’s policy titled, “Emergency Department Patient Assessment, Vital sign Management, and Reassessment Policy” last revised 10/2025 states in part, “II. Definitions: ...Vital Signs: Includes...pain assessment... III. Procedure ...All reassessments must be documented in the EMR [Electronic Medical Record]... ...Vital signs are also repeated...within one hour after administration of pain medication... Escalation and Communication LIP [Licensed Independent Practitioner] must be notified of abnormal vital signs ...” Record review for Patient ID #4 revealed she/he presented to the Emergency Department in November of 2025 at 9:35 AM complaining of worsening swelling of the right foot. The record indicated that orders for morphine (a medication used to treat pain) and ketorolac (Toradol) (a medication used to treat pain) were placed. According to Patient ID #4’s record, morphine was administered intravenously at 12:05 PM and Toradol was administered intravenously at 4:41 PM. At the time that both medications were administered, the patient’s pain level was documented, however, the patient’s pain level was not reassessed 1 hour after either pain medication was administered in accordance with hospital guidelines and policy. Record review revealed that Patient ID #8 presented to the Emergency Department in October of 2025 at 9:01 AM complaining of abdominal pain that radiated to his/her back for two days. Patient ID #8 was then evaluated by an Emergency Department physician at 12:46 PM who indicated in his assessment of the patient that the patient was experiencing “abdominal tenderness” and “guarding”. The record indicated that an order for intravenous acetaminophen (Ofirmev), a medication used to treat pain, was placed and then administered at 1:28 PM. At the time of administration, the patient’s pain level was documented as “severe” with a score of 7/10. Further record review for Patient ID #8 revealed that the patient’s pain level was obtained at 2:27 PM by Employee R, a Patient Care Technician, approximately one hour after Ofirmev was administered. At that time, the patient’s pain level was documented as “severe,” with a score of 7/10. However, the record failed to reveal evidence that a Registered Nurse or a provider was notified of the patient’s persistent “severe” pain. By 6:13 PM, approximately 3 hours and 40 minutes later, Patient ID #8 was marked as “eloped” from the Emergency Department. The record failed to reveal evidence that a Registered Nurse followed up with the patient and documented in the EMR a subsequent pain reassessment or interventions addressing the patient’s persistent pain. During a surveyor interview and a review of patient records on 11/10/2025 at approximately 1:30 PM with Employee C, the Emergency Department Quality and Safety Manager, she was unable to provide evidence that pain reassessments were completed an hour after pain medications were administered for Patient ID #s 4 and 8. 3. The hospital’s policy titled, “Emergency Department Patient Assessment, Vital sign Management, and Reassessment Policy” last revised 10/2025 states in part, “...Vital Signs Guidelines ...Vital signs are also repeated when...abnormal... Escalation and Communication LIP [Licensed Independent Practitioner] must be notified of abnormal vital signs...” Record review for Patient ID #1 revealed she/he presented to the Emergency Department in October of 2025 at 8:41 PM, stating she/he had been “running from the cops” for two hours. Vital signs obtained for Patient ID #1 at 8:58 PM showed that his/her blood pressure was elevated at 174/116 mmHg (normal range per the American Heart Association is less than 120/80 mmHg) and his/her heart rate was elevated at 118 beats per minute (normal heart rate typically ranges from 60 to 100 beats per minute). Employee S, a Patient Care Technician, documented in the record that a Registered Nurse was made aware of the patient’s elevated blood pressure. However, the record failed to reveal evidence that the patient’s blood pressure and heart rate were rechecked or that the LIP was notified of the abnormal blood pressure and heart rate in accordance with hospital guidelines and policies. Record review for Patient ID #2 revealed she/he presented to the Emergency Department in November of 2025 at 2:06 AM complaining of 10/10 chest pain. Vital signs obtained for Patient ID #2 at 6:17 AM showed that his/her blood pressure was elevated at 200/96 mmHg. Employee T, a Patient Care Technician, documented in the record that a Registered Nurse was made aware of the patient’s elevated blood pressure. However, the record failed to reveal evidence that the patient’s blood pressure was rechecked or that the LIP was notified of the abnormal blood pressure in accordance with hospital guidelines and policies. Record review for Patient ID #8 revealed she/he presented to the Emergency Department in October of 2025 at 9:01 AM complaining of abdominal pain that radiated to his/her back for two days. Vital signs obtained for Patient ID #8 at 9:05 AM showed that his/her blood pressure was elevated at 181/105 mmHg. Employee U, a Patient Care Technician, documented in the record that a Registered Nurse was made aware of the patient’s elevated blood pressure. However, the record failed to reveal evidence that the patient’s blood pressure was rechecked or that the LIP was notified of the abnormal blood pressure in accordance with hospital guidelines and policies. During a surveyor interview on 11/10/2025 at 12:53 PM with Employee P, Emergency Department Flow Manager, he indicated that after the Registered Nurse is made aware of an abnormal vital sign, there should be a follow-up note written to confirm their acknowledgement of the abnormal value. 4. Record review for Patient ID #2 revealed she/he presented to the Emergency Department in November of 2025 at 2:06 AM complaining of 10/10 chest pain. The record revealed that Patient ID #2 was assessed by a physician at 7:05 AM. The physician indicated that he reviewed the patient’s electrocardiogram results which showed that the patient had a prolong QT interval (a condition in which the heart’s electrical system is slowing down between beats, which can increase the risk of abnormal rhythms), indicating that magnesium would be administered to address this. Further record review revealed that magnesium sulfate was ordered at 7:25 AM to be administered intravenously at 7:30 AM. However, this medication was not administered until 12:03 PM, 4 hours and 33 minutes after it was scheduled for administration. Record review for Patient ID #4 revealed she/he presented to the Emergency Department in November of 2025 at 9:35 AM complaining of worsening swelling of the right foot. The record indicated that orders for morphine and Ondansetron (Zofran) were placed at 10:34 AM and subsequently scheduled for administration at 10:45 AM. However, both morphine and Zofran were not administered until 12:05 PM, 1 hour and 20 minutes after both medications were ordered. Additionally, orders for ketorolac (Toradol) and dexamethasone (Decadron) (a medication used to treat inflammation) were placed at 12:31 PM to be administered intravenously at 12:45 PM. However, Toradol and Decadron were not administered until 4:41 PM and 4:45 PM respectively, approximately 4 hours and 10 minutes after both medications were scheduled for administration. During a surveyor interview on 11/4/2025 at 2:50 PM with ED Employees F, G and H, ED Registered Nurses, they acknowledged that Patient ID #4 had a delay in receiving their pain medication. During a surveyor interview on 11/10/2025 at approximately 1:30 PM with the Emergency Department Nursing Director, she acknowledged that in accordance with the standards of nursing practice, ordered medications are to be administered 1 hour before or up to 1 hour after their scheduled times.”

“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 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 maintaining compliance with the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC). Please refer to the following: -A-0701-Failure to develop and maintain the physical plant in such a manner that the safety and well-being of patients are assured. -Form CMS-2567 Life Safety Code report.”

“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 surveyor observation 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 related to fire safety. Findings are as follows: The Rhode Island Department of Health received notification from the State Fire Marshal’s Chief Deputy informing of the hospital’s non-compliance with Life Safety Code requirements. This notification prompted an investigation for regulatory compliance. Review of an email sent from the Office of the State Fire Marshal’s Chief Deputy to Employee ID# 2, dated 4/3/2025, revealed that the hospital had been informed that the exit access corridor and the associated exits from an exterior trailer used as the temporary site for sterile reprocessing, were not in compliance with the Life Safety Code requirements. During a surveyor observation of the mobile unit located on hospital grounds housing the temporary site for sterile reprocessing, on 4/4/2025 at approximately 9:25 AM, the following concerns were identified in the presence of the Fire Marshal, Employee ID# 2, and Employee ID# 1: -The secondary emergency exit from an exterior sterile reprocessing trailer was blocked by chain link fencing and parked cars. -The primary entry/exit doorway of the exterior sterile reprocessing trailer led to an exit access corridor that was constructed with wood frame construction and lacked fire alarm or sprinkler protection. During a surveyor interview with the Employee ID# 2, on 4/4/2025 at the time of the above-mentioned observation, he acknowledged the concerns listed above. He indicated that a fire watch detail had been established on 4/3/2025 and implemented on 4/4/2025 early morning, per the Fire Marshal’s directive until the structure is removed.”

“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 record review and staff interview, it was determined that the hospital failed to enforce its rules and regulations established for the medical staff relative to the documentation of progress notes in the medical record for 1 of 2 patients reviewed (Patient ID #1). Additionally, the hospital failed to ensure that a Third Year Resident who is part of the hospital’s code team was up to date with their Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certifications in accordance with hospital policy (Employee B). Findings are as follows: The hospital’s “Medical Staff Rules and Regulations” state in part, “ ...V. Medical Records ...3. Progress Notes: Pertinent progress notes shall be recorded at the time of evaluation, sufficient to permit continuity of care and transferability. Whenever possible, each of the patient’s clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatments ...” Review of Patient ID #1’s Medical Record, revealed a Significant Event Note dated 1/4/2025 written by Employee A, Registered Nurse, stating that while rounding she heard sounds coming from the patient’s room and went in to check on the patient. The note revealed Patient ID #1 then told the nurse that she/he accidentally spilled hot coffee on themselves. The Registered Nurse then applied cold washcloths to the skin and notified the On-Call Resident. The note then revealed that the intern came to assess the patient and recommended petroleum jelly to the skin. Patient ID # 1’s medical record revealed no evidence of any documentation from the physician, regarding their assessment of the the injury or treatment order for the injury on 1/4/2025. During a surveyor interview on 1/21/2025 at 2:00 PM with Employee B, Third Year Medical Resident and Attending Physician, Employee C, and First Year Intern, Employee D, the patient’s medical record was reviewed. Employee B, Third Year Medical Resident, confirmed that she was covering the patient on the day she/he received the burns. She acknowledged that she received a call from the patient’s nurse, Employee A, stating that Patient ID #1, spilled hot coffee on themselves and needed to be seen. The resident then stated that she sent the intern to see the patient. She then confirmed that she did not see the patient’s injury on 1/4/2025. The Intern, Employee D, was then asked if she was the intern who went up to evaluate the patient on 1/4/2025. She stated that she was not. Employee B then revealed that she had sent Employee E, First Year Resident, to evaluate the patient. Both the Attending and the Third Year Resident could not provide evidence of physician notes documenting that the patient was evaluated on 1/4/2025 despite the patient being seen by the first year resident on 1/4/2025. Employee C was then asked if it is his expectation that an intern or resident should write a note after they see a patient, to which he answered yes and that it was dependent on the situation. 2. Review of the hospital’s policy titled “BLS and ACLS for House Officers” states in part: “Policy ...All house officers will maintain BLS and ACLS certification consistent with Rhode Island Hospital policy in effect during their training period ...” Record review of the medical staff credentialing files on 1/21/2025 revealed that Employee B, Third Year Resident, has been practicing with an expired BLS and ACLS certification since 6/30/2024. During an interview with the Chief Resident, Employee F, on 1/21/2025 at 3:30 PM, she confirmed that Employee B has continued to participate in the Hospital’s Code Team responses from July 2024 to Present. 45769”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of 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 develop a plan of care in accordance with their hospital policy and Federal regulations for the use of restraints for 3 of 6 patients reviewed, Patient ID#’s 1, 2 and 3. Findings are as follows: Review of the hospital’s policy titled “Lifespan Patients Restraint and Seclusion” last reviewed 11/2023, states in part: “...III. Procedure ...Initiation of Restraint or Seclusion Action 6. Modify the Plan of Care Update the plan of care based on initial and ongoing assessment...” Record review for Patient ID #1 revealed the patient was admitted to the Medical Intensive Care on 9/29/2024 with Respiratory Failure. On 9/30/2024 a physician order was placed for nonviolent restraints to maintain the integrity of their lines and tubes. The medical record lacked evidence that the Plan of Care was modified following the initiation of the restraints. Record review for Patient ID #2 revealed the patient was admitted to the Neuro Critical Care Unit on 9/25/2024 with a Left Internal Carotid Artery Occlusion. On 10/10/2024, a physician order was placed for nonviolent restraints to maintain the integrity of their tubes and invasive lines. The medical record lacked evidence that the Plan of Care was modified following the initiation of the restraints. Record review for Patient ID #3 revealed the patient was admitted to the Trauma Intensive Care on 10/10/2024 with Multiple Trauma Injuries. Upon admission to the unit a physician order was placed for nonviolent restraints to maintain integrity of their tubes and invasive lines. The medical record lacked evidence that the Plan of Care was modified following the initiation of restraints. During an interview with the Risk Manager on 10/15/2024 at approximately 11:30 AM, she was unable to produce evidence that the patient’s Plan of Care was updated to include the use of restraints.”

“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: 32374 Based on record review, hospital policy review, and staff interview, it was determined that the hospital failed to administer medications in accordance with hospital policy and the rights of medication administration practice. Findings are as follows: The hospital failed to ensure a nurse verified and scanned the right medication prior to it’s administration to the patient. This failure resulted in a patient receiving the incorrect medication requiring an immediate intervention. On 3/29/2024, the hospital submitted an abatement plan indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. On 4/1/2024 an audit was completed by the state surveyors. Verification of policy review, and staff education records were verified. Interviews with staff was conducted which indicated staff had knowledge of the incident and corrective measures. (Refer to A-0395)”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 32374 Based on record review, hospital policy review, and staff interview, it was determined that the hospital failed to administer medications in accordance with hospital policy, and the Eight (8) Rights of Medication Administration Practice for 1 of 7 patients reviewed for medication administration, Patient ID #1. Findings are as follows: Record review for Patient ID #1 revealed a physicians order for a nicardipine drip (an intravenous (IV) medication used to treat high blood pressure). This medication was noted to have been administered by an insulin drip (an intravenous medication used to decrease elevated blood sugars) in error. This error resulted in the patient suffering a low blood sugar, then requiring the patient to receive an IV solution of Dextrose 50% and Dextrose 10% (medications used to treat low blood sugars). Review of the hospital’s policy titled, “Medication Administration, System Admin 110,” last revised on 1/2024 states in part, “ ...Eight (8) Rights of Medication Administration Practice 1. Right Patient ... 2. Right Medication: the correct medication, to ensure that the medication being given to the patient matches that prescribed for the patient ... 3. Right Dose ... 4. Right Route ... 5. Right Time ... 6. Right Documentation ... document administration prior to administering the ordered medication. Barcode scanning should be utilized. 7. Right Reason ... 8. Right Response ...” Record review revealed Patient ID #1 presented to the emergency department in March of 2024 after striking their head and sustaining a laceration following a fall. Upon arriving to the hospital, the patient was confused, and had garbled speech . Diagnostic imaging confirmed bilateral subdural hematomas (a condition due to bleeding under the membrane covering the brain). The patient underwent a left craniotomy (a surgical operation on the skull) to remove the hematoma and was subsequently admitted to the Neurosciences Critical Care Unit. The patient’s medical history includes, but is not limited to, high blood pressure, low potassium, glaucoma, and a ventriculoperitoneal shunt (a surgical procedure to implant a device that relieves pressure on the brain due to excess fluid). Review of a Significant Event Note dated 3/24/2024 revealed that the patient received approximately 35 to 45 units of regular insulin which required an IV infusion of Dextrose 50% and Dextrose 10% to reverse the effects of the insulin drip. Further review revealed that nursing staff were advised to perform finger sticks every 15 minutes for 4 hours to check blood sugar levels. Review of a physician progress note dated 3/25/2024, confirmed that Patient ID #1 was administered Dextrose 10% as the insulin drip was administered accidentally. During a surveyor interview with Employee A, Registered Nurse, on 4/1/2024 at 9:05 AM, she stated that when walking by Patient ID #1’s room she observed that the nicardipine drip being infused into the patient was almost empty. In response to this, she stated she then retrieved a new bag of nicardipine from the nicardipine bin within the Omnicell, and quickly “hung” the new IV bag of nicardipine, without scanning because another patient was attempting to “jump out of bed” and required her immediate attention. Upon returning to Patient ID #1’s room she then scanned the IV bag of medication she had just hung and was alerted that this medication was not nicardipine as was ordered. She identified that the infusion was insulin instead of nicardipine. When questioned, Employee A acknowledged she did not scan the nicardipine drip prior to administering it to Patient ID #1 and indicated she only looked at the color of the box, which is confirmed to be similar for both insulin and nicardipine.”

“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: 32374 45769 Based on record review and staff interview it has been determined that the hospital failed to ensure an effective transition of a patient from the hospital to a skilled nursing facility for post-discharge care, due to the failure to list the patients insulin on the medication list provided to the skilled nursing facility on the continuity of care form for 1 of 5 patients reviewed who were prescribed insulin upon discharge (Patient ID #1). Findings are as follows: The hospital failed to identify the patients insulin regimen on the continuity of care form upon transfer to a skilled nursing facility, (Refer to 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: 32374 45769 Based on record review and staff interview it has been determined that the hospital failed to discharge and transfer a patient with the necessary medical information pertaining to a new insulin regimen for 1 of 5 patients reviewed who was prescribed insulin upon discharge to a skilled nursing facility, (Patient ID #1). Findings are as follows: A community reported complaint was submitted to the Rhode Island Department of Health on 12/15/2023 alleging that a patient was transferred to the skilled nursing facility with no insulin order. Record review revealed that Patient ID #1 was admitted to the hospital in November of 2023 with a diagnosis of left emphysematous pyelonephritis (an acute severe necrotizing infection of the kidney) and hepatic encephalitis (a severe infection of the brain). The patient also has a past medical history of diabetes. Review of the patient’s hospital record revealed a medication administration record (MAR) dated December 2023 containing the following insulin administration order: Insulin Lispro Injection 0-8 units per sliding scale Dose: 0-8 units Frequency: 3 times a day with meals Route: Subcutaneously Review of the Continuity of Care (COC) form that the skilled nursing facility received at the time of discharge on 12/14/2023, revealed the following information: “Continue these medications which have NOT CHANGED ... U-100 insulin syringe ultra fine, 30 gauge x ½ syringe, use 1 new syringe to inject insulin from vial 3 times a day before meals.” The COC form failed to reveal an order or instructions for insulin administration. During a surveyor interview with the Pharmacy Patient Safety Director on 12/19/2023 at 10:35 AM, he stated that the pharmacy is alerted to review all insulin discharge orders to confirm correct dosage, however, they would not be alerted to complete a medication review if a physician orders insulin syringes without ordering insulin therefore, Patient ID #1’s discharge orders were not reviewed. During a surveyor interview with the patient’s attending physician, Employee A, who completed the discharge on 12/19/2023 at 11:00 AM, she confirmed that she completed the patient’s discharge, and she ordered the patient’s sliding scale of Lispro Insulin. The surveyor then asked the physician to review the discharge orders, and upon her review she acknowledged that she only ordered the insulin syringes three times a day and did not order the Lispro Insulin sliding scale as intended. The physician stated that her intent was to continue the patient on the sliding scale at the skilled nursing facility. During a surveyor interview with the Assistant Clinical Manager of CO-OP 3, on 12/19/2023 at 1:00 PM, she stated that the nursing staff completes the discharge paperwork which includes the last time the patient received each medication. She confirmed that the nurse does not look at the copy of the COC that is sent to the facility because it is generated from what the physician enters into the computer which is then faxed to the skilled nursing facility. The Assistant Clinical Manager reviewed Patient ID #1’s medication reconciliation that was completed by the attending physician and failed to see that insulin syringes were ordered.”

“ANESTHESIA SERVICES CFR(s): 482.52 If the hospital furnishes anesthesia services, they must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The service is responsible for all anesthesia administered in the hospital. This Condition is not met as evidenced by: 32374 45769 Based on record review and staff interviews it has been determined that the hospital failed to ensure safety practices are consistent with recognized standards of practice for anesthesia care for 1 of 6 patients reviewed who received the wrong medication during a surgical procedure (Patient ID #1). Refer to A-1002”

“DELIVERY OF ANESTHESIA SERVICES CFR(s): 482.52(b) Anesthesia services must be consistent with needs and resources. Policies on anesthesia procedures must include the delineation of pre-anesthesia and post-anesthesia responsibilities. The policies must ensure that the following are provided for each patient: This Standard is not met as evidenced by: 45769 Based on record review and staff interviews it has been determined that the hospital failed to provide Anesthesia services that are consistent with recognized standards for anesthesia care and safety practices for 1 of 6 patients reviewed (Patient ID #1) , related to the incorrect medication administration of a vasopressor (drug that causes constriction of the blood vessels), that was intended to be an antiemetic (drug used to prevent nausea and vomiting). Findings are as follows: A report submitted to the Rhode Island Department of Health on 12/4/2023 by the hospital’s Risk Manager revealed that on 11/28/2023 a patient undergoing surgery received a dose of IV Phenylephrine, when IV Zofran was intended resulting in hypertension (increased blood pressure). The patient required additional treatment. Review of the hospital’s policy titled, “Medication Administration” states in part, ...Five Rights of Medication Administration Practice 1. Right Patient 2. Right Medication: ensure that the medication being given matches what has been prescribed ... 3. Right Dose: Ensure that the dosage of the medication matches ... 4. Right Route 5. Right Time ...Before Administering Medications For all medication administration, the individual administering the medication does the following: 1. Verifies the five rights ... 4. Visually inspects the medication ... Record review for Patient ID #1 revealed an Operative Note Report dated 11/28/2023 at 7:30AM, indicating the patient underwent an elective robotic assisted laparoscopic (minimally invasive surgical technique) removal of a pelvic mass, right ovary, and fallopian tube. The note included: Complication(s): Hypertensive emergency following the incorrect IV medication administration. Review of the OR medication list revealed Patient ID #1 received 10 mg(milligrams) of Phenylephrine IV (intravenous) at 12:07 PM. Review of a Vascular Neurology Consult Note dated 11/28/2023 at 2:42PM stated the following, 80-year-old female admitted 11/28/2023, underwent laparoscopic removal ...She received Phenylephrine intraoperatively and her “systolic blood pressure shot to 250” ... During a surveyor interview with the third year Anesthesia Resident, Staff A on 12/5/2023 at 2:00PM, she confirmed that she was assigned to Patient ID #1’ s OR case. Staff A stated that on 11/28 at 12:05PM, she removed two medications for Patient ID #1, one vial Sugammadex 400 mg (drug used to reverse anesthesia agents) and one vial of Zofran 4mg (antiemetic). Staff A stated that she removed both medications from the top drawer of the anesthesia omni cell (secured storage cabinet). She then stated that she drew up each medication vial into a separate syringe and administered both into Patient ID #1’s intravenous line. Staff A stated that she noticed that Patient ID #1’s blood pressure was elevated following the administration of these medications and notified her attending physician. At that time, the two medication vials were reviewed with the attending physician, and it was discovered that the patient did not receive Zofran as intended but had received Phenylephrine in error. Staff A acknowledged that she did not inspect the medication vial of Phenylephrine close enough to assure that it was the right medication. She did acknowledge she had received education regarding the 5 rights of medication administration.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 45769 Based on policy review, record review and staff interview it has been determined that the hospital failed to administer medications in accordance with hospital policy for 1 of 4 patient’s reviewed for subcutaneous heparin administration, Patient ID #1. Findings are as follows: A report submitted to the RI Department of Health on 11/16/2023 by the hospital’s Risk Manager revealed that on 11/13/2023, a patient was administered, 100 units of insulin in error, after the nurse selected the insulin vial instead of the heparin vial. The patient required additional interventions including Glucagon, Dextrose 5%, 10% and 50%. Review of the hospital’s policy titled, “Medication Administration, System Admin 110” states in part, ...Five Rights of Medication Administration Practice 1. Right Patient 2. Right Medication: ensure that the medication being given matches what has been prescribed ... 3. Right Dose: Ensure that the dosage of the medication matches ... 4. Right Route 5. Right Time According to the Lippincott procedure “Medication Administration and Monitoring Checklist, published in January 2007, the five rights of medication administration include verifying, prior to medication administration, that the right patient is being administered the right medication at the right dose, at the right time and by the right route. Review of Patient ID #1’s medical record revealed that the patient was admitted to the hospital on 11/12/2023 with extreme weakness, facial droop, and aphasia. Past medical history includes but is not limited to diabetes, and hypertension. Review of a Significant Event Note dated 11/13/2023 at 5:35 PM revealed the following information: “notified by nursing that the patient received 1 ml subcutaneous insulin injection ... Endocrinology up to evaluate patient ... frequent glucose checks, and IV dextrose ordered ... During a surveyor interview with Registered Nurse, Staff A on 11/20/2023 at 1:30 PM she explained to this surveyor that Patient ID #1 had been off the floor for several hours due to diagnostic testing on 11/13/2023. Upon their return she went into the patient’s room to administer their medications, which included, insulin sliding scale, 5000 units of heparin subcutaneously, and an IV antibiotic. Staff A stated she administered the sliding scale dose of insulin according to the order in the presence of a second nurse verifier who left the room after the insulin was administered. She then stated that she scanned the heparin and the antibiotic and proceeded to hang the IV antibiotic. She then stated she intended to administer the heparin and she grabbed the vial off the computer tray and drew up 1 ml. and administered the medication to the patient. When she turned around, she noticed the unopened vial of heparin and realized that she had drawn up insulin instead of heparin, administering 100 units of insulin to the patient. During the interview she confirmed that she was talking to the family who was at the patient’s bedside, and she just grabbed the vial and drew it up without looking at the label to confirm that it was the heparin. During a surveyor interview with the Assistant Clinical Manager on 11/20/2023 at 1:30PM she revealed that Staff A entered her office on 11/13/2023 at approximately 2:15PM to notify her of the medication error that was made and that the patient’s physician had been notified of the error.”