Kent County Memorial Hospital

“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 policy review, record review, and staff interviews, the hospital failed to ensure that nursing personnel adhered to the hospital’s policy regarding the documentation of pain reassessments following the administration of pain medication for 2 of 4 patients reviewed, (Patient ID #s 1 and 2). Findings are as follows: The hospital’s policy titled “Pain Management” states, in part: “Reassessment of Pain...reassessments will occur following pain medication administration or pain intervention. All reassessments are documented in the medical record...Staff can refer to the Lippincott procedures for best practice.” The hospital’s referenced Lippincott Manual identifies the expected reassessment time frames as 15 to 30 minutes following intravenous pain medication administration and within 1 hour following oral pain medication administration. Record review revealed that Patient ID #1 presented to the Emergency Department in June of 2026 initially reporting shortness of breath and chest pain. On 6/25/2026 at 1:00 PM, Patient ID #1 received acetaminophen (Ofirmev), a medication used to treat pain, intravenously. A pain reassessment was not documented 15 to 30 minutes following medication administration in accordance with hospital policy and practice guidelines. On 6/25/2026 at 3:12 PM and on 6/26/2026 at 12:04 AM and 7:58 AM, Patient ID #1 received oxycodone (Roxicodone), a medication used to treat pain, via the oral route. A pain reassessment was not documented within 1 hour following medication administration in accordance with hospital policy and practice guidelines. Record review revealed that Patient ID #2 presented to the Emergency Department in April of 2026 reporting a fever, weakness, decreased food intake and abdominal pain. The record indicated that Patient ID #2 received hydromorphone (Dilaudid), an opioid medication used to treat pain, intravenously on the following dates and times: - 4/19/2026 at 1:00 PM, 6:23 PM, and 9:46 PM - 4/20/2026 at 1:19 AM, 5:27 AM, and 8:55 AM Further review revealed that Patient ID #2 also received ketorolac (Toradol), a nonsteroidal anti inflammatory medication used to treat pain, intravenously on 4/19/2026 at 5:20 PM. However, the record failed to reveal evidence that a pain reassessment was documented within 15 to 30 minutes after each of the above listed administrations in accordance with hospital policy and practice guidelines. During a surveyor interview on 7/23/2026 at approximately 11:45 AM with the Nurse Director of the Emergency Department, she was unable to provide evidence that pain reassessments were documented for the patients listed above in accordance with the hospital’s policy and practice guidelines following pain medication administration.”

“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 record review, staff and patient interviews, the hospital failed to adhere to the requirements of patient rights after the following was identified: 1. The hospital failed to inform patients of their rights. (A-0117) 2. The hospital did not ensure that patients in the locked behavioral health area of the emergency department, awaiting behavioral health treatment had their hygiene needs addressed on a daily basis. (A-0143) 3. The hospital did not ensure that the restraint used for an elderly patient in the Emergency Department was the least restrictive option available. (A-0165) 4. The hospital failed to ensure that restraints were applied in accordance with physician orders. (A-0168) 5. The hospital failed to ensure that a face-to-face evaluation is documented in accordance with hospital policy. (A-0179)”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 43881 Based on surveyor observation, record review, and staff interviews, the hospital did not ensure that patients in the locked behavioral health area of the Emergency Department were informed of their rights as required for hospital patients for 2 of 2 individuals reviewed who were petitioned for emergency certification., (Patient ID #s 7 and 9). Findings are as follows: According to 216-RICR-40-10-4, TITLE 216 - Department of Health, Chapter 40 - Professional Licensing & Facility Regulation, Subchapter 10 - Facilities Regulation, Part 4 - Licensing of Hospitals, “a copy of the Rights of Patients shall be given to each patient or his/her representative upon admission and shall be posted in a conspicuous place on the premises.” 1a. During a surveyor interview with Patient ID #7 on 2/27/2026 at 9:41 AM, the patient alleged that staff did not explain his/her rights while he/she was in the behavioral health area of the Emergency Department and did not provide a printout or other information regarding his/her rights as a patient. Record review revealed that Patient ID #7 presented to the Emergency Department in February 2026 for a psychiatric evaluation due to paranoia and delusions and was placed in Care Team 2, a locked behavioral health area within the Emergency Department. On 2/12/2026, the emergency department provider indicated that Patient ID #7 had been in the emergency department greater than 24 hours and per hospital policy, the patient’s case was discussed with the hospitalist, and she/he was admitted. The record indicated that on 2/12/2026, after evaluation by a psychiatric nurse practitioner, the patient was documented as “considered to be acutely and chronically mild to moderate risk of harm to [herself/himself] or others,” and an application for emergency certification was completed. The record failed to reveal evidence that the patient was informed of his/her rights as a patient or provided with information related to those rights until he/she requested this information from staff on 2/14/2026, approximately two to three days after presenting to the Emergency Department and being petitioned for emergency certification for meeting criteria for inpatient psychiatric services. 1b. Record review for Patient ID #9 revealed that the patient presented to the Emergency Department in February 2026 for a psychiatric evaluation after reportedly not taking prescribed medications and not attending outpatient appointments. Further record review revealed that Patient ID #9 had a physician order for admission on 2/12/2026. Upon arrival to the Emergency Department, the patient was placed in Care Team 2, a locked behavioral health area within the Emergency Department. The record indicated that on 2/12/2026, after evaluation by psychiatry, an application for emergency certification was completed due to the patient being disorganized, lacking capacity to make treatment decisions, and being confused. The record failed to reveal evidence that the patient or the patient ’ s representative was informed of his/her rights as a patient or provided with information related to those rights. During a surveyor interview on 3/4/2026 at 10:45 AM with Registered Nurse Staff A, she stated that patient rights are only provided upon request and that providing them is not a routine part of the nursing process. During a surveyor interview on 3/4/2026 at 10:50 AM with Mental Health Worker Staff B, she stated that patient rights are not typically discussed with patients but that a list of rights is available if a patient requests it. During a surveyor interview on 3/4/2026 at 12:26 PM with Social Worker Staff C, she stated that providing patients with their rights is not a routine part of their process. During surveyor observations of Care Team 2 on 2/27/2026 at approximately 1:45 PM and on 3/4/2026 at approximately 10:45 AM, no posting of the Rights of Patients was observed. During a surveyor interview on 3/4/2026 at approximately 11:00 AM with the Nursing Director of the Emergency Department, she confirmed that the Rights of Patients were not posted within Care Team 2 for patients to review.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 43881 46539 Based on record review, staff, and patient interviews, the hospital failed to ensure that a patient ’ s basic right to dignity and comfort was upheld, as the medical record did not demonstrate that the patient ’ s personal hygiene was addressed daily in accordance with hospital policy for 1 of 3 patients reviewed (Patient ID #7). Findings are as follows: The hospital ’ s policy titled, “Management of the Behavioral Health Patient,” effective 4/1/2023, states in part: “ ...III. Standards of Practice for Behavioral Health Patients ... 2. Each patient ’ s personal hygiene is addressed daily ...” A complaint submitted to the Rhode Island Department of Health in February 2026 alleged that Patient ID #7 did not have access to hygiene supplies or clean underclothes for three days. During a surveyor interview with Patient ID #7 on 2/27/2026 at 9:41 AM, the patient stated that no one told him/her that he/she could ask for a toothbrush. Record review for Patient ID #7 revealed s/he presented to the Emergency Department in February 2026 for a psychiatric evaluation due to paranoia and delusions. Further record review revealed a patient progress note dated 2/13/2026 at 12:53 PM indicating that the patient was provided with hygiene products. However, the record did not document that the patient had been provided with hygiene products from the time of presentation to the Emergency Department on the morning of 2/11/2026 until 2/13/2026. During a surveyor interview on 3/4/2026 at 10:45 AM with the Mental Health Worker, Staff B, Registered Nurse Staff A, and the Nursing Director of the Emergency Department, none could provide evidence that Patient ID #7 was offered, provided, or refused hygiene supplies from 2/11/2026 through 2/13/2026, until the patient requested them.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 43881 Based on clinical record review and staff interviews, the hospital failed to demonstrate that the type of restraint used on a patient was the least restrictive intervention attempted for 1 of 3 patients reviewed for violent restraints (Patient ID #9). Findings are as follows: The hospital ’ s policy titled “Restraint Use” defines violent restraints as: “ ...(Behavioral): Used in emergencies to manage violent/aggressive behavior that may jeopardize the immediate physical safety of the patient, staff, or others (i.e., punching, hitting, kicking, biting, etc.).” The policy further states, in part: “Only the least restrictive type and level of restraint will be used to accomplish the prevention of harm ... Any application of restraint must involve consideration of the degree and likelihood of harm that may be prevented by the restraint compared to the degree and likelihood of the harm produced by the restraint, with special consideration given to patient populations at greater risk of harm, for example ... elderly patients.” Clinical record review for Patient ID #9 revealed that this elderly patient, with a medical history including, but not limited to, schizophrenia, presented to the Emergency Department in February 2026 for a psychiatric evaluation after reportedly not taking medications and not attending outpatient appointments. Upon arrival, the patient was placed in Care Team 2, a locked behavioral health area within the Emergency Department. According to the patient ’ s record, at 7:40 PM on 2/12/2026, security personnel applied keyed limb restraints to both wrists and both ankles, with the left arm positioned up and the right arm positioned down, due to being an “imminent risk of harm to self and others.” Record review of restraint documentation indicated that the patient was “agitated/restless,” “verbally abusive,” hallucinating, and confused. A physician order for “Violent or Self-Destructive” locked restraints was signed by Employee E, Physician, at 7:40 PM on 2/12/2026. The order stated that a physician “must conduct a face-to-face assessment within 1 hour of initiation.” However, the record failed to document that a face-to-face assessment was completed. Review of the Patient Observation Record dated 2/12/2026 indicated the patient was under observation for being “Restrained for violent behavior.” Further review of this record in conjunction with the Violent Restraints Monitoring form revealed that, although the patient was “agitated,” “verbally abusive,” “restless in bed,” “calling out,” and “pulling devices” while restrained, the patient was not documented as “combative.” While the medical record indicated that staff attempted decreased stimulation, verbal redirection, and reorientation to surroundings, it did not demonstrate that the patient displayed violent or aggressive behaviors, such as punching, hitting, kicking, or biting, as outlined in hospital policy prior to the application of violent locked restraints. The record also failed to show that the use of this type of restraint represented the least restrictive intervention necessary. During a surveyor interview on 3/5/2026 at 10:49 AM, Registered Nurse Staff F stated that the patient was extremely agitated and believed his/her son was under the bed. The patient reportedly removed the mattress from the bed and continued searching for his/her son. Staff F administered medication and then instructed security personnel to apply 4-point keyed limb restraints according to Care Team 2 protocol. During a surveyor interview on 3/6/2026 at 11:46 AM, Security Officer Staff G stated that he responded after the patient in Care Team 2 was acting erratically and searching under the bed for his/her son. He reported that Staff F instructed the team to apply restraints. Two restraints were applied to the patient ’ s upper limbs and two to the lower limbs. Staff G stated that after the restraints were applied, the patient continued calling out for his/her son and did not attempt to fight while restraints were being applied. During a surveyor interview on 3/5/2026 at 2:00 PM, the Nursing Director of the Emergency Department explained that after de-escalation attempts fail and restraints are necessary, the nurse instructs security to apply 4-point keyed limb restraints. She confirmed that staff do not attempt any other form of restraint prior to 4-point restraints and that no written restraint protocol exists for Care Team 2.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43881 Based on clinical record review and staff interviews, the hospital failed to ensure that the use of restraints was provided in accordance with the orders of the physician or other licensed practitioner responsible for the patient ’ s care for 1 of 3 patients reviewed for behavioral restraints (Patient ID #8). Findings are as follows: Record review revealed that Patient ID #8 presented to the Emergency Department for evaluation of mania. Further review indicated that the patient became aggressive toward staff and was subsequently restrained both chemically and physically. The patient was later transferred to the Intensive Care Unit (ICU) on 12/15/2025. Record review identified physician orders for a therapeutic hold (a method of restraint in which a person ’ s freedom of movement or normal access to their body is restricted by staff physically holding the person for safety reasons) on the following dates and times due to the patient being a danger to self: 12/17/2025 at 6:10 AM 12/17/2025 at 10:09 AM 12/17/2025 at 1:51 PM 12/17/2025 at 6:16 PM 12/17/2025 at 10:15 PM 12/18/2025 at 2:24 AM Review of the restraint flowsheet revealed that the patient was placed in keyed restraints (used to secure a patient ’ s wrists and ankles to a bed or gurney, typically in emergencies when a patient poses an immediate threat to self or others) during these dates and times, rather than the therapeutic hold ordered by the physician. During a surveyor interview on 3/6/2026 at 12:26 PM, the ICU Director stated that the patient was never placed in a therapeutic hold and that she was unaware of the specifics of the therapeutic hold. She confirmed that the patient remained in keyed restraints while in the ICU, rather than in the physician-ordered therapeutic hold. During a surveyor interview on 3/6/2026 at approximately 9:00 AM, the Assistant Chief Nursing Officer was unable to provide evidence that the physician orders for therapeutic holds corresponded to the restraints applied to the patient on 12/17/2025 and 12/18/2025.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 43881 Based on clinical record review and staff interviews, the hospital failed to provide evidence that a face-to-face evaluation was documented within 1 hour after the initiation of restraints for 3 of 3 patients reviewed for restraints (Patient ID #s 8, 9, and 10). Findings are as follows: The hospital ’ s policy titled “Restraint Use,” effective 9/2/2025, states in part: *”Violent Restraint (Behavioral): Used in emergencies to manage violent/aggressive behavior that may jeopardize the immediate physical safety of the patient, staff, or others (i.e., punching, hitting, kicking, biting, etc.). ...Restraint Order for Violent Behavior ...The APC [Advanced Practice Provider]/Provider must complete a face-to-face evaluation within 60 minutes of restraint application, even if the restraint is removed in less than one hour. The APC/Provider documents the face-to-face evaluation of the patient to include the immediate situation: the reaction of the patient, the patient ’ s medical and behavioral condition, and the need to continue or terminate the restraint.”* Patient ID #8 Record review revealed that Patient ID #8 presented to the Emergency Department for evaluation of mania. The patient became aggressive toward staff and was restrained chemically and physically. Physician orders for violent restraints were entered and initiated at the following times: 12/13/2025: 1:31 PM, 3:34 PM 12/14/2025: 12:41 AM, 1:19 PM, 4:57 PM, 9:58 PM 12/15/2025: 2:17 AM, 8:57 AM 12/16/2025: 4:00 AM, 2:53 PM 12/17/2025: 6:10 AM (behavioral restraint) 12/18/2025: 7:33 AM (behavioral restraint) Record review failed to demonstrate that a face-to-face evaluation was documented within 1 hour of each restraint initiation, including documentation of the patient ’ s immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint as required by hospital policy. Patient ID #9 Record review revealed that Patient ID #9 presented to the Emergency Department in February 2026 for a psychiatric evaluation after reportedly not taking medications or attending outpatient appointments. The patient was documented as “agitated/restless,” “verbally abusive,” hallucinating, and confused. A physician order for violent restraints was entered for keyed limb restraints, and the patient was restrained by the wrists and ankles. Record review failed to demonstrate a face-to-face evaluation within 1 hour of restraint initiation, including assessment of the patient ’ s immediate situation, reaction, medical and behavioral condition, and the need to continue or terminate the restraint per hospital policy. Patient ID #10 Record review revealed that Patient ID #10 presented to the Emergency Department in March 2026 for evaluation of altered mental status. The patient became agitated, swinging and yelling at nursing and security personnel. A physician order for behavioral restraints was entered for keyed limb restraints, and the patient was restrained by the wrists and ankles. Record review failed to demonstrate a face-to-face evaluation within 1 hour of restraint initiation, including assessment of the patient ’ s immediate situation, reaction, medical and behavioral condition, and the need to continue or terminate the restraint per hospital policy. During surveyor interviews on 3/5/2026 at 2:06 PM and on 3/6/2026 at approximately 9:00 AM, the Assistant Chief Nursing Officer was unable to provide evidence that a face-to-face assessment was documented in the medical records for Patient ID #s 8, 9, and 10 in accordance with hospital policy following orders for violent restraints.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 43881 Based on clinical record review and staff interviews, the hospital failed to ensure that the After Visit Summary discharge instructions were accurate for 1 of 1 patient reviewed who was receiving Scemblix, (a medication used to treat chronic myeloid leukemia, a slow-growing cancer of the blood-forming cells in the bone marrow. (Patient ID #3). Findings are as follows: A community-reported complaint was submitted to the Rhode Island Department of Health on 2/6/2026, alleging that Patient ID #3 was discharged with instructions to stop taking Scemblix. The complainant further stated that it was not until follow-up with the patient ’ s hematologist/oncologist several weeks later that they were informed the patient should have continued taking Scemblix following discharge. Record review revealed that Patient ID #3, with a history of CML, presented to the Emergency Department in October 2025 due to uncontrolled bilateral lower extremity pain and was admitted with a non-ST-segment elevation myocardial infarction (NSTEMI) (a common type of heart attack). Review of the hospital-provided After Visit Summary for Patient ID #3 following the inpatient stay indicated that the patient was discharged with instructions to stop taking Scemblix 40 milligrams. Record review revealed that on 10/20/2025, Internal Medicine Resident Staff J spoke with the patient ’ s hematologist/oncologist, who agreed that Scemblix could be held during the inpatient stay. During a surveyor interview on 3/5/2026 at 9:55 AM, the patient ’ s physician, Staff K, acknowledged that the After Visit Summary instructed the patient to stop taking Scemblix and confirmed that discontinuation of Scemblix following hospitalization was an error and should not have occurred.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 32374 Based on record review, policy review, and staff interviews, it was determined that the hospital failed to meet §482.55 Condition of Participation: Emergency Services after the following was identified: The Emergency Department staff failed to follow the hospital’s triage protocol relative to verifying patients’ allergies. This failure resulted in an Immediate Jeopardy, that placed patients at risk of serious harm, serious impairment or death. (Refer to 1104) Findings are as follows: A Centers for Medicare/Medicaid Service (CMS) authorized Federal substantial allegation survey was completed from 9/9/2025 through 9/11/2025 at Kent County Memorial Hospital to determine compliance with §482.55 Condition of Participation: Emergency Services. It was determined that the hospital was not in substantial compliance with the requirements of §482.55 Condition of Participation: Emergency Services after a patient who was evaluated in the emergency department (ED) was administered an antibiotic which they had a confirmed allergy to. Staff failed to follow established policies and procedures of the ED, as the staff neglected to thoroughly review all of the documents that were provided with a patient when they were transferred to the ED from the transferring facility, prior to administering medications. As a result of the identified non-compliance, Patient ID #1 was administered a medication that he/she was allergic to. The hospital was informed of the Immediate Jeopardy and was provided with the Immediate Jeopardy template on 9/10/2025 at approximately 12:00 PM, after it was identified. On 9/10/2025, 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: - The development of a Nursing Practice Alert that would direct all ED nurses to review all documentation accompanying a patient who was transferred into the ED from an outside facility. This Practice Alert will be issued to all Nurses via email and will be posted at all ED nursing stations. - A formal protocol was to be immediately drafted to provide guidance to registered nurses regarding the management of information appearing on documentation accompanying patients who are transferred to the hospital from an outside facility. - All Emergency Department Nurses on all shifts would receive in-person, onsite education, prior to the start of their shift, until all ED nurses have received the training. The following materials were reviewed as part of the training: a. Kent Hospital ED Protocol: Review of External Documentation from External Facilities b. Practice Alert: Allergy Verification Required: Every Patient, Every Time All Emergency Department Nurses on all shifts were required to conduct a “Read and Sign” of the above training. The ED Triage Competency Check List will now include “Review the Continuity of Care Form or any other Discharge/Transfer Form” that may accompany a patient from an outside transferring facility and confirm and reconcile all allergies against the existing allergies listed in the electronic medical record. The following hospital policies were revised: KH-NUR-610 - Medication Reconciliation Policy would now include COC and Discharge/Transfer forms to the list of “appropriate and reliable sources” for medication reconciliation. KH-NUR-607 - Medication Administration Policy (Section IV(c)(4) Points of Emphasis would now include COC and Discharge Forms from outside facilities in the list of sources where allergies are confirmed prior to administering a medication. KH-ED-036 - Assessment/Reassessment of patients in the Emergency Room policy (Section IV (f)(2) Procedure) would include specific guidance to review all documentation that accompanies a patient from an outside transferring facility for allergies and other pertinent information. On 9/11/2025 at 1:30 PM the State Survey Agency confirmed the above plan was implemented through observation of the triage process, record review, and interviews with multiple nurses in the ED confirming that staff had received, reviewed, and were implementing the above training and received the education.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 32374 Based on record review, policy review, and staff interviews, it has been determined that the hospital failed to ensure that the emergency department (ED) staff followed the hospital’s triage process related to verifying a patient’s allergies for 1 of 5 patients reviewed, Patient ID #1. This failure resulted in a patient receiving an antibiotic intravenously (IV) that they had a known allergy to. Findings are as follows: On 9/8/2025, The Rhode Island Department of Health received a complaint in which the family of Patient ID #1 alleged that when they arrived at the ED the patient was receiving Vancomycin (an antibiotic) via IV, a medication that the patient had a known allergy to. Review of the hospital’s policy titled, “Assessment/Reassessment of Patients in the Emergency Department”, effective 2/12/2025 states in part: “...The ED RN’s [registered nurse’s] initial assessment data will include. But is not limited to... (2) Chief complaint. Pain severity, allergies ...” Review of Patient ID #1’s ED record revealed the patient was transferred via Emergency Medical Services (EMS) from a skilled nursing facility on 9/4/25, with lethargy and a low grade fever. The patient’s spouse presented to the ED and observed intravenous Vancomycin medication being infused into the patient. S/he alerted the staff of the patient’s allergy, and asked them to discontinue it. Review of the “Transfer and Discharge Report “, which accompanied the patient when they arrived to the ED from the skilled nursing facility, revealed that the patient was allergic to Vancomycin. Review of the Rhode Island EMS Patient Care Report dated 9/4/2025, under “Medication Allergies” identified that the patient was allergic to Vancomycin. Review of the initial patient assessment completed by Nurse Staff A, upon arrival in the ED, revealed the following was checked off as completed: ...allergies were “reviewed and documented.” Review of the ED medication orders for Patient ID #1 revealed that Vancomycin 925 mg IV had been ordered by ED Attending Physician, Staff B. During a surveyor interview on 9/10/2025 at 11:51 AM with Staff A, she stated that she had received a verbal report from EMS for Patient ID #1 when s/he arrived presented to the ED and began her assessment of the patient. She confirmed that she had also received transfer paperwork from the skilled nursing facility, which she glanced over. She stated the patient’s family was not present when the patient initially arrived, and the patient was nonverbal. Staff A stated she reviewed the patient’s allergies in the hospital’s electronic record system. Additionally, Staff A revealed that once Patient ID #1’s spouse arrived in the ED on 9/4/2025, and saw that the patient was receiving IV Vancomycin, s/he informed her that the patient was allergic to Vancomycin. The infusion was then stopped and she notified Staff B. During a surveyor interview with, Staff B, on 9/10/2025 at 12:10 PM, she stated that she had reviewed the patient’s allergies that were recorded in the hospital’s electronic medical record. Staff B confirmed that she was unaware of the patient’s allergy to Vancomycin. During an interview with the Director of Risk Management, Staff C, on September 9, 2025, at 3:00 PM, she acknowledged that the skilled nursing facility’s “Transfer and Discharge Form” and The Rhode Island Emergency Medical Services “Run Sheet” listed that the patient had an allergy to Vancomycin. Additionally, she acknowledged that the patient’s hospital electronic was not updated to include his/her allergy to Vancomycin and should have been.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 43881 Based on record review, policy review, and staff interviews, the hospital failed to meet §482.55 Condition of Participation: Emergency Services after the following was identified: 1. Emergency department staff failed to follow established policies and procedures in the emergency department regarding the review and clarification of new prescriptions upon discharge, (Refer to 1104). 2. An emergency department provider prescribed a new medication to a patient with a documented allergy, resulting in the patient experiencing an adverse drug reaction, (Refer to 1104). These failures resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment or death to all patients. Findings are as follows: A Centers for Medicare/Medicaid Service (CMS) authorized Federal substantial allegation survey was completed on 7/3/2025 at Kent County Memorial Hospital to determine compliance with §482.55 Condition of Participation: Emergency Services. It was determined that the hospital was not in substantial compliance with the requirements of §482.55 Condition of Participation: Emergency Services after a patient who was evaluated in the emergency department was prescribed a new medication at discharge to which they had a documented allergy. Staff failed to follow established policies and procedures in the emergency department related to reviewing and clarifying new prescriptions with patients upon discharge and ensuring patients’ allergies are confirmed prior to prescribing medications. As a result of the identified non-compliance, Patient ID #1 was prescribed a medication she/he was allergic to upon discharge from the emergency department. The patient then took the medication as prescribed and experienced symptoms including itchy/scratchy throat and tightening of muscles in the throat and shoulders. The hospital was informed of the Immediate Jeopardy identified on 7/2/2025 and was provided with the Immediate Jeopardy template at approximately 1:50 PM on this date. On 7/3/2025, 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: - Developed a Nursing Practice Alert outlining the step-by-step process for discharging a patient in the Emergency Dept. In addition to general discharge steps, this Practice Alert specifically addresses clarification of discharge orders with the provider and review of new prescriptions issued to the patient. - Immediately, this Practice Alert will be issued to all Nurses via email and AMS intra-hospital texting mechanism. - Immediately, all Emergency Department Nurses on all shifts will receive onsite education to review: a. KH-ED-029 Discharge of the ED Patient b. Practice Alert: Process for Discharge of Emergency Department Patients c. Discharge documents provided to patients: Patient Visit Summary, Emergency Services - Discharge Instructions - Immediately, all Emergency Department Nurses on all shifts will be required to conduct a “Read and Sign” of KH-ED-029 Discharge of the ED Patient. - Immediately, all ordering providers on all shifts in the Kent Hospital Emergency Dept. will receive in-person, onsite education related to decision support allergy alerts and medication prescription management. - Immediately, when prescribing new medications to an emergency department patient, all ordering providers will be required to document the generic and name brand of the medication in the “Follow Up Care” field in the provider note. This action will cause the generic and name brand of the medication to auto populate into the ED Patient Education document that is used by the discharging RN to review with the patient upon discharge. The patient also receives a copy of this document for reference post-discharge. - Immediately, the Chief of Emergency Medicine will issue an email with High Importance instructing all prescribing providers to: a. Carefully review and verify all patient allergies before prescribing or administering medications. b. Carefully contemplate all decision support allergy alerts that may trigger during the ordering process. c. Document the generic and name brand of new medications prescribed to the patient during the encounter in the “Follow Up Care” field in their provider note so that this information auto populates into the patient’s Discharge Education documentation. - Kent Hospital utilizes an electronic medical record implemented by Cerner Software. When a patient has a documented allergy, the decision support software fires an allergy alert “pop up.” Currently, prescribing providers have multiple override choices when contemplating whether to prescribe a medication to a patient who has a documented allergy. To mitigate confusion and augment the prescribing provider’s use of discretion when selecting a reason for override, the Decision Support allergy alert override reasons have been revised to only display three acceptable options: 1. Home med taken w/out reaction 2. Patient being monitored 3. Free Text On 7/3/2025, the State Survey Agency confirmed during a review of medical records from patients discharged from the emergency department and interviews with nurses and physicians on duty in the emergency department, that staff had received, reviewed, and implemented training related to reviewing and clarifying new prescriptions and confirming patient allergies. As of 7/3/2025, the Immediate Jeopardy was removed.”

“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 record review, surveillance video review, and staff interview, the hospital failed to ensure a patient’s right to receive care in a safe setting was upheld when excessive force was used during the application of a restraint, for 1 of 3 patients reviewed, (Patient ID #1). Findings are as follows: On 6/13/2025, Patient ID #1 submitted a complaint to the Rhode Island Department of Health alleging that while in the emergency department, she/he was restrained with excessive force and punched in the face resulting in bruising and injury to his/her left wrist and right fourth finger. Record review revealed the patient presented to the emergency department in June of 2025 via ambulance after making suicidal statements. Record review of nursing progress notes revealed that Staff I asked the patient to hand over his/her phone, however, the patient indicated that she/he would hand his/her phone over after she/he finished sending a text message. According to Staff G, “after about a minute,” Staff I asked the patient to hand over the phone again, to which the patient replied while yelling, she/he was not finished. Staff I then “took the phone” from the patient at which point she/he began to yell derogatory terms at Staff I. Staff G stated that that she and Staff H attempted to deescalate the patient as Staff I walked away with the patient’s phone. However, the patient was not receptive, she/he unbuckled himself/herself from the stretcher, “lunged toward [Staff H] to try and push his/her out of the way to get to [Staff I]” who had his/her phone, while telling Staff G and Staff H to “Shut the f*** up.” Staff J then intervened and attempted to guide the patient to a hallway chair, however, both the patient and Staff J fell to floor along with Staff I, both of which held the patient down on the floor to prevent the patient from “swinging at staff.” Additional personnel and Staff K were then summoned to the scene. According to Staff G, the patient then began to scream that his/her back was in pain due to his/her recent surgery, however “proceeded to try and kick at staff.” Following the arrival of extra personnel and Staff K, the patient began spitting at Staff J, who used his open hand to guide the patient’s chin to the side to prevent the patient from spitting on his face. Staff G indicated that Staff K ordered restraints for the patient as she/he continued to “verbally assault staff”, “thrash”, and “hit staff”. When the patient was assisted to a standing position, she/he attempted to “violently kick” staff and was then “guided” into a patient room where his/her limbs were held down by staff for the restraints to be applied. During the application of restraints, the patient was “trying to knee staff”, “tried to fight staff” and tried to spit at Staff J, at which point Staff J again “guided” the patient’s face away in the same manner as before. Staff G indicated that a spit mask was applied to the patient and the patient was “threatening to hit staff” yelling, “you’re breaking my wrists I felt a pop, my arm is broken!”, “you guys broke my hands” and “that guy punched me in the face!” Staff G further stated that Staff K attempted to deescalate the patient and assess him/her but she/he continued to “yell and thrash” and sedating medications were ordered and administered. Staff G indicated that despite their attempts to deescalate patient and medicating him/her, the patient “continued to thrash in bed and yell out” and was observed on camera removing his/her wrist restraints which were reapplied. Record review of a Musculoskeletal Assessment performed by Staff G on 6/11/2025 at 7:30 PM, revealed the patient had tenderness on their right and left wrists, and edema (swelling) and tenderness on a finger of the right hand. Record review of Staff K’s documentation revealed that staff reported to him that the patient was asked multiple times to stop texting and turn his/her phone over. Staff K indicated that although the patient was “given time to comply”, the patient did not, and staff “attempted” to retrieve the phone, and the patient became “highly assaultive and started kicking staff”. Upon his arrival, the Staff K indicated that the patient was lying on the floor “attempting to kick staff”, “screaming”, and “resisting”. Staff K stated that he observed staff attempting to stand the patient at which point he observed the patient “violently kick” multiple staff who then “tackled” him/her onto a patient bed where 4-point restraints were applied. According to Staff K, the patient reported she/he “felt a snap” in his/her left wrist and pain in his/her fourth finger of the right hand. Record review of a Physical Examination performed by Staff K revealed that the patient had a “deformity” at the tip of the right fourth finger. Record review of Staff H’s documentation revealed Staff H was inside of the nurses’ station when she observed the patient typing on his/her phone when she/he was approached by Staff I who was requesting his/her phone. Staff H indicated that the patient began yelling and refused to hand his/her phone over at which point, Staff I attempted to physically remove the phone from the patient’s hands. Staff H stated that the patient said she/he was “texting my sister that I’m here” and “give me a moment”. Staff H indicated that she observed Staff I “step back in apparent agreement” but “after several seconds” when the patient continued to text, Staff I attempted to remove the phone from the patient’s hands again while she/he continued to yell and refuse. Staff H indicated that upon exiting the nurses’ station, Staff I had “disengaged” from the patient with his/her phone in his hand. Staff H stated that she then observed the patient unbuckle himself/herself from the stretcher while screaming at Staff I to return his/her phone, she/he jumped off the stretcher, and grabbed at Staff H in an attempt reach Staff I who had retrieved his/her phone. Staff J then intervened and restrained the patient with Staff I while the patient screamed, flailed, kicked, grabbed, and hit Staff J and Staff I. According to the Staff H, the patient was assisted to stand, struggled, and kicked staff and was assisted to a patient room where restraints were applied, but the patient continued to scream, verbally aggress toward staff and repeatedly yell “shut the f*** up”. Staff H stated that throughout the episode, the patient stated that she “had a broken back”, “they punched me in the face!”, “they punched me in the jaw”, “they broke my finger!”, “they broke my wrist!”, and “they cracked my wrist!” The record indicated that the patient eventually calmed, restraints were removed, she was medically cleared and then transferred to another hospital for further management. Record review of the patient’s discharge documentation revealed that the patient’s associated diagnoses included “finger sprain”. During a review of recorded surveillance video in the presence of Staff E on 7/3/2025 at 12:49 PM, the patient was observed arriving on the unit laying on a stretcher accompanied by ambulance personnel. The patient was observed holding his/her cell phone with both hands, actively engaging with the device as the screen was visibly illuminated. Staff I was observed attempting to retrieve the patient’s phone from his/her hands multiple times and is at one point observed holding the patient’s left arm attempting to retrieve his/her cell phone from their right hand as she/he waved if away from Staff I. The patient was observed pulling away from Staff I’s grasp followed by a brief physical exchange between them as the patient pulled his/her cell phone away from him and as he tried to retrieve the phone. Staff I was then observed stepping back and as the patient was actively engaging with his/her cell phone again, Staff I approached the patient quickly and abruptly removing the cell phone from the patient’s hands. The patient in turn jumps up from the stretcher while still being strapped in, removed the buckle, and then lunges himself/herself onto staff as if heading towards Staff I who had taken his/her cellphone. Staff J is then observed holding the patient and Staff I lunges toward the patient. The patient, Staff I, and Staff J end up on the floor and both Staff I and Staff J were observed holding the patient down on the floor. Multiple staff are observed entering the area including Staff K. The patient is then brought up to his/her feet and escorted by Staff I, Staff J and another staff member. The patient is visibly struggling and fighting against staff and is then observed being tackled onto a patient bed. Staff J was observed holding the patient’s left hand in place and at one point is observed placing his hand on the patient’s left cheek, guiding the patient’s face away from himself. Staff I was observed landing on the bed along with the patient while holding the patient’s right hand and arm and straddling his/her right leg with both of his legs. When additional staff intervene, Staff I completely disengages with the patient and the patient is then observed grabbing Staff I’s shirt from his right shoulder. Staff I was then observed grasping the patient’s right hand and eventually throws himself on top of the patient while she/he is being restrained onto the bed. During a surveyor interview with Staff E following the review of surveillance footage, she agreed that Staff I escalated the patient by abruptly removing the patient’s phone from his/her hands which caused the patient to react aggressively and violently toward staff. Staff E was informed that Staff K’s description of the incident, stating that the patient was “tackled” onto a patient bed, was consistent with what was observed on surveillance video substantiating the allegation that excessive force was used during a restraint.”

“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 record review and staff interview, it was determined that the application of a restraint was in accordance with the order of a physician after a nurse who reviewed the order failed to ensure that the restraint order was written correctly by the physician according to the type of restraint applied to a patient for 1 of 3 patients reviewed, (Patient ID #13). Findings are as follows: The hospital’s policy for “Restraint Use” defines “Violent Restraint (Behavioral)” as “Used in emergencies to manage violent/aggressive behavior that may jeopardize the immediate physical safety of the patient, staff, or others. (i.e., punching, hitting ...” According to the hospital’s “Restraint Documentation” protocol for nursing staff, the nurse needs to “ensure that the physician’s order for restraint is written correctly according to the type of restraint applied to the patient ...” Record review revealed that Patient ID #13 became “very excited” and appeared to be “disassociated from reality”, was not redirectable and was “speaking unintelligibly”, shouting and “under a great amount of stress”. The patient then began punching the wall, injured his/her right hand, and attacked staff before being restrained. According to the record, “keyed” limb restraints were applied to the patient’s left wrist and ankles. Record review revealed that Staff L entered an order for the initiation of restraints due to the potential for self-harm. The order stated that stated, “soft” restraints were to be applied to the patient’s ankles and wrists for 24 hours as the patient was interfering with medical devices. Further record review revealed that Staff M reviewed this restraint order after Staff L entered it into the medical record. During a surveyor interview on 7/3/2025 at 9:00 AM with Staff M, he indicated that soft restraints are never used on patient that is physically violent and instead “keyed” limb restraints are used. Staff M indicated that he usually ensures that the appropriate restraint order is entered into the medical record according to what is applied to the patient. During a surveyor interview on 7/2/2025 at 9:15 AM with Staff F, she indicated that she would expect Staff M to ensure that the appropriate restraint order is entered in the medical record for the type of restraint applied to the patient.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 43881 Based on record review, policy review, and staff interviews, the hospital failed to ensure that emergency department staff adhered to established policies and procedures regarding the provision of discharge instructions and the review and clarification of new prescriptions in the emergency department for 5 of 8 patients reviewed (ID #s 1, 2, 4, 5, and 6). This failure resulted in one emergency department provider prescribing oxycodone to a patient (ID #1) with a documented allergy to oxycodone. The newly prescribed medication was not included in the discharge instructions for the nurse to review and clarify, and the patient took the medication as prescribed while at home and experienced an adverse drug reaction. Findings are as follows: The hospital’s policy titled, “Discharge of the ED [Emergency Department] Patient”, effective 11/24/2024 states in part: “ ...(5) The discharging nurse will review and clarify discharge orders and any new prescriptions and convey the information to the patient/family. (6) Discharge instructions will include information regarding care at home, prescriptions and any follow-up visits recommended by the treating ED LIP [Emergency Department Licensed Independent Provider] ...” On 6/9/2025, The Rhode Island Department of Health received a complaint in which Patient ID #1 alleged they were prescribed Percocet (a medication that contains a combination of oxycodone and Tylenol used to provide relief from pain) upon discharge from the emergency department despite being allergic. The patient alleged that they confirmed their allergy to Percocet with multiple people in the emergency department including a Physician Assistant and was provided with a bright red allergy bracelet. Patient ID #1 indicated they took the medication because she/he thought the generic name on the bottle, oxycodone (a medication used to provide relief from pain), was Vicodin (a medication that contains a combination of hydrocodone and Tylenol used to provide relief from pain). During a surveyor interview on 7/1/2025 at 9:22 AM with Patient ID #1, she/he revealed that while taking the newly prescribed oxycodone at home, she/he experienced an “itchy/scratchy” feeling in his/her throat as well as “tightening of muscles” in his/her shoulders and throat. Record review revealed Patient ID #1 presented to the emergency department in June of 2025 with complaints of abdominal pain. Review of the emergency department documentation revealed a list of allergies which included “Percocet 7.5/325 (a medication that contains a combination of oxycodone and Tylenol used to provide relief from pain) with an associated symptom of “difficulty breathing.” The record indicated that while in triage, the patient’s allergies were “reviewed and documented” by Staff A. Further review of the emergency department documentation revealed that Staff B prescribed the following medications to Patient ID #1 at discharge: - Oxycodone - Naloxone (medication used to reverse overdose from narcotics) - Tylenol (medication used to relieve pain and fever) - Keflex (antibiotic) - Zofran (medication used to relieve nausea and vomiting) Record review of discharge documents (“Patient Visit Summary” and “Emergency Services - Discharge Instructions”) provided to the patient upon discharge, failed to reveal evidence that the newly prescribed medications were included in these documents. During a surveyor interview on 7/1/2025 at 2:15 PM with Staff C, he indicated that in his practice, he does not tell the patient the specific medications they are prescribed upon discharge nor how to take the medication since he does not have visibility of which medications have been prescribed by the provider. Staff C indicated that if the provider were to write the name and dose of the medications prescribed to the patient in the discharge instructions, he would review this information with the patient. During a surveyor interview on 7/2/2025 at 10:45 AM with Staff B, she indicated she prescribed oxycodone to the patient as the patient was to avoid anti-inflammatories due to their condition and indicated she did not remember discussing the new prescription for oxycodone with the patient. Staff B indicated she typically reviews a patient’s allergies, however, does not remember doing so for this patient. Staff B indicated she did not remember getting a warning alert from the system when she entered oxycodone as a newly prescribed medication. When asked what she would do differently, Staff B stated she would not prescribe oxycodone and would prescribe a different medication, such as Norco (a medication that contains a combination of hydrocodone and Tylenol used to provide relief from pain) to help control the patient’s pain at home. During a surveyor interview on 7/1/2025 at approximately 3:00 PM and on 7/2/2025 at approximately 2:00 PM with Staff E, she confirmed that according to Staff F, when a provider enters a new prescription in the medical clinical documentation system in the emergency department, the newly prescribed medication does not populate in the discharge instructions for the nurse to review upon discharge. Staff E then indicated that according to their policy, “Discharge of the ED Patient”, new prescriptions are to be discussed and reviewed with patients. In addition, Staff E revealed that Staff B received a warning alert from the clinical documentation system specific to Patient ID #1’s allergies when she entered the prescription for oxycodone. She indicated that Staff B overrode the warning alert and selected “defer to provider” as the reason for the override. During an additional review of patients who were discharged from the emergency department with new prescriptions for the month of June 2025 entered by Staff B and other providers, it was determined that the documents provided to the following patients upon discharge demonstrated noncompliance with hospital policy and inconsistent practice relative to newly prescribed medications. Record review revealed that Patient ID #2, who presented to the emergency department in June of 2025 due to abdominal pain, was discharged home with a prescription for Zofran and oxycodone per Staff B. However, the Emergency Services- Discharge Instructions and the Patient Visit Summary failed to reveal evidence that the newly prescribed medications were included in these documents for the nurse to review and clarify in accordance with hospital policy. Record review revealed that Patient ID #4, who presented to the emergency department in June of 2025 due to flank pain and was diagnosed with a kidney stone, was discharged home with a prescription for Augmentin, an antibiotic, per Staff B. However, the Emergency Services- Discharge Instructions and the Patient Visit Summary failed to reveal evidence that this newly prescribed antibiotic was included in these documents for the nurse to review and clarify in accordance with hospital policy. Record review revealed that Patient ID #5, who presented to the emergency department in June of 2025 due to dental pain, was discharged home with a prescription for Augmentin and oxycodone per Staff B. However, the Emergency Services- Discharge Instructions and the Patient Visit Summary failed to reveal evidence that these newly prescribed medications were included in these documents for the nurse to review and clarify in accordance with hospital policy. Record review revealed that Patient ID #6, who presented to the emergency department in June of 2025 due to abdominal pain, was discharged home with a prescription for Flomax (a medication used to alleviate difficulty urinating), ketorolac (a medication used to help treat pain), and nitrofurantoin macrocrystals (an antibiotic) per Staff D. However, the Emergency Services- Discharge Instructions and the Patient Visit Summary failed to reveal evidence that these newly prescribed medications were included in these documents for the nurse to review and clarify in accordance with hospital policy.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition 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 meet the Condition of Participation: Pharmaceutical Services relative to the hospital’s failure to prevent a medication error caused by the administration of a NSAID (non-steroidal anti-inflammatory drug) medication to a patient with an identified severe ibuprofen allergy, causing them to have an anaphylactic reaction requiring additional clinical interventions. Findings are as follows: The hospital failed to follow its own policy titled, “Medication Management- Adult Patients” relative to reviewing the medication order for patient allergies or potential sensitivities as well as, clarifying concerns, issues, or questions with the prescribing provider prior to dispensing and administering the medication, (Refer A-0500).”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 45769 Based on record review and staff interview the hospital failed to follow its own policy “Medication Management- Adult Patients” relative to the reviewing of the medication order for patient allergies or potential, as well as clarifying concerns, issues, or questions with the prescribing provider prior to dispensing and administering the medication. This resulted in a medication error that required additional clinical interventions for Patient ID #1. Findings are as follows: On 1/3/2025, the hospital submitted an incident report to the Rhode Island Department of Health which indicated that on 12/29/2024 Patient ID #1 received a dose of Toradol (a non-steroidal anti-inflammatory medication used to treat pain) when it was documented in the patient’s electronic medical record that they had a severe allergic reaction to Ibuprofen which is classified as an non-steroidal anti-inflammatory medication. The report states shortly after administration of the medication, Patient ID #1 experienced an anaphylactic reaction which necessitated additional clinical interventions other than monitoring. The following hospital policy was reviewed: 1). The hospital’s policy titled, “Medication Management” last reviewed 3/11/2022 states in part, “...IV. Procedure all patient clinical information is readily accessible to personnel involved in the medication management system. - The patient’s allergies and sensitivities ...” “...Procedure ...#26. The Pharmacist reviews all medication orders for the following: ...* Patient allergies or potential sensitivities #27. Concerns, issues, or questions are clarified with the prescriber prior to verifying the order and dispensing the medication...” #28. Pharmacists’ clarifications and interventions are documented electronically in the patients’ electronic medical record ... #44. Before administering a medication, the practitioner administering the medication performs the following: ...Verifying that there are no contraindications (including allergies) for administering the medications ...” Review of the medical record revealed that Patient ID #1, is a 43 year old who presented to the hospital’s Emergency Room on 12/29/2024, with a chief complaint of rectal pain. CT imaging revealed perianal inflammatory stranding with a fluid collection along the right gluteal cleft measuring 2.5 X 2.3 cm without tracking gas. A surgery consult was completed, and the decision was made to admit the patient with a plan for surgery in the morning. Review of the medical record revealed an order written by the Surgical Physician Assistant (PA), Staff A for ketorolac (Toradol), 15 (milligrams) mg IV push every six hours, 0n 12/29/2024 at 6:41 PM. The order was electronically submitted to the hospital’s pharmacy and was acknowledged and reviewed by Registered Pharmacist, Staff B on 12/29/2024 at 6:46 PM. The record further revealed that the medication was administered to the patient by Registered Nurse, Staff C on 12/29/2024 at 6:41 PM prior to the pharmacy verification. Review of the medical record revealed a list of the patient’s allergies which included Ibuprofen,with a response of Anaphylaxis (A severe potentially life threatening allergic reaction). Review of an Acute Event Note dated 12/29/2024 revealed that a Rapid Response was initiated at 7:52 PM after the patient was noted to be flushed and vomiting. The patient was complaining of tingling lips, along with Gastrointestinal symptoms. The Emergency Room attending physician responded immediately and the patient was administered 0.3 mg of epinephrine ( medication used to treat severe allergic reactions) prior to the arrival of the Rapid Response Team. Review of the Rapid Response Note revealed, Patient ID #1, appeared flushed, with mild duskiness to his/her legs and appeared uncomfortable. She/he was without stridor, or wheezes and the lungs were clear. The patient complained of feeling like his/her throat was closing. During the event the patient received the following additional medications: - Solumedrol 60 mg IV - 2 doses of Epinephrine - Benadryl IV During a surveyor interview with the Surgical PA, Staff A and Chief of Surgery, on 1/9/2025 at 9:00 AM, the PA stated that he completed the History and Physical and admission orders for Patient ID #1. When asked if he was aware of the patient’s allergies, he remembered seeing the allergy alert pop up while he was placing the orders and said that he saw so many pop up warnings that he could have “blown by” the ibuprofen allergy alert. During a surveyor interview with Pharmacist, Staff B on 1/9/2025 at 11:00AM, he revealed that he was the pharmacist that checked the patient’s medication orders. He then stated that when he checked the orders, he did not remember seeing the alert pop up identifying the allergy to Ibuprofen. The pharmacist acknowledged that the patient’s medical record contained the information that the patient was allergic to Ibuprofen, and it was listed as a severe allergy/anaphylaxis. The pharmacist then stated that he takes full responsibility of the event. During a surveyor interview with the Clinical Pharmacy Manager. Staff D, on 1/9/2025, she stated that it is her expectation that the pharmacist would have investigated the order further. She explained that when the provider chooses to defer to provider it is the pharmacist’s responsibility to validate that the issue has been addressed and it is ok to sign off the medication so that it can be administered. During a surveyor interview with RN, Staff C, on 1/9/2025 at 12 noon, she explained the process of medication administration stating that the process includes reviewing the medication, identifying the patient, asking about allergies, and scanning the medication. The RN was then asked if the patient had an allergy band on at the time she was administering the medications. She then replied that she could not remember, stating that she usually asks the patient if they are allergic to any medications when she is medicating them and this time she did not, acknowledging that she did not follow the hospital’s policy. During a surveyor interview with the Risk Manager’s on 1/8/2025 at 11:00 AM, they confirmed that the both the physician and the pharmacist received a warning alert notifying them that the patient has a severe allergy, listing Ibuprofen/anaphylaxis when the Toradol was entered. The warning alert requires a response by entering a reason to override the medication in a drop down box. According to the documentation provided by the Risk Managers the PA chose Defer to Provider to override the warning. The pharmacist then verified the order after responding to the allergy override as Pharmacist Consulted without contacting the PA for clarification.”