Emma Pendleton Bradley Hospital

“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, staff interviews, and a review of hospital practices and policies, the hospital failed to ensure that staff completed education regarding the process for handling and securing television remotes following an incident in which Patient ID #1 ingested two AAA batteries obtained from an unsecured television remote. Additionally, leadership staff confirmed there was no formal training during orientation related to the process for handling television remotes. This deficient practice was identified for 1 of 2 patients reviewed who ingested non-food items. Findings are as follows: On 5/27/2026, the hospital reported to the Rhode Island Department of Health that on 5/24/2026 around 10:30 AM, Patient ID #1 reported to staff that she/he had swallowed two AAA batteries that she/he took from a remote control she/he found on a counter. The report further indicated that the patient was transferred to another hospital and was admitted for observation. Record review revealed that Patient ID #1 was admitted to the hospital for safety, stability and medication management in April of 2026 from an outside hospital where she/he was brought to the Emergency Department for suicidal ideation and self-injurious behavior following the ingestion of perfume and barricading himself/herself in a room. According to the record, on 5/24/2026 the patient reported to nursing staff that she/he had swallowed two AAA batteries from a television remote at approximately 10:00 AM with suicidal intent. Although staff indicated that the patient was not in acute distress and was alert and oriented, the patient reported feeling “warm” and had mild throat pain. The record indicated that the patient was evaluated by the physician following the incident. The physician indicated that when she asked the patient about swallowing the batteries, the patient stated, “I don’t deserve to live” and “let’s see if this works.” Record review revealed that the patient was transferred to another hospital for evaluation and treatment. During a surveyor interview on 6/1/2026 at 2:04 PM with the Risk Manager, she stated that on the morning following the incident, Facilities was asked to apply Gorilla Tape to the back of the remote to secure the battery compartment cover. She explained that this had been standard practice many years ago; however, due to turnover among nursing and Facilities personnel, the practice had not been consistently maintained. She stated that a patient had previously swallowed batteries from a television remote, which led to the implementation of taping the battery compartment covers. She further explained that the patient in this incident found a remote, hid it from staff, and later informed staff that she had swallowed the batteries. During a surveyor interview on 6/2/2026 at 1:15 PM and at 2:41 PM with the Clinical Manager of AIU, Employee A, she revealed that she reviewed recorded video footage of the incident. According to her review, on the evening prior to the incident, staff were in the activity room with patients while the television was in use. She stated that the video showed a Behavioral Health Specialist (BHS), Employee B, turning off the television, and while holding the remote, turning off the lights. Before leaving the room, however, Employee B stopped at the door, turned around and placed the remote on the ledge in front of the television. She stated that Employee B was new to the hospital and had not been trained in the process for handling television remotes. She revealed that at the time, no BHS supervising staff (BHS-3), who are responsible for handling television remotes, were on duty because they were out sick. She explained that after the remote was placed on the ledge, the activity room door was closed. The following morning, the video showed the patient experiencing difficulty, and a different staff member opened the activity room door for this patient without realizing that the television remote had been left unsecured. The patient was then observed taking the remote and placing it in his/her pocket while staff were looking away. When asked who is responsible when no BHS-3 staff are on duty, she stated that the Charge Nurse assumes that responsibility. When asked whether staff had been educated regarding the Charge Nurse’s responsibility for handling television remotes in the absence of BHS-3 staff, she confirmed that they had not been informed and stated that she would address this during staff meetings. The Clinical Manager of AIU further revealed that there is no formal training during orientation regarding the handling of television remotes for BHS-3 staff. She confirmed that following the incident, education for nursing staff and all BHS staff was initiated on 5/26/2026 but had not yet been completed.”

“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: 46539 Based on clinical record review and staff interviews, the hospital failed to ensure physician orders were obtained immediately following the use of physical holds and the use of the seclusion room for 2 of 7 patients reviewed, Patient ID #s 1 and 2. Findings are as follows: The hospital’s policy titled, “Patient Restraint and Seclusion,” defines restraints as “Any intrusive method of suppressing the ability of the person to move their arms, legs, body, or head freely; or have normal access to their body due to equipment attached to, or adjacent to the patient...” The policy also defines a violent restraint as “The use of restraint or seclusion when warranted by violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others.” The policy further states that “If the ordering provider is not present, the RN [Registered Nurse] will contact the ordering provider to obtain the order” and “In an emergency situation where the order cannot be obtained prior, the order must be obtained during the emergency application of restraint or immediately after (within minutes) the restraint was initiated. If an order is not obtained immediately, it will be considered restraint without an order.” 1. Record review revealed that Patient ID #1 was admitted to the hospital in October of 2025 with a diagnosis including, but not limited to, anxiety disorder. The patient’s medical record failed to reveal evidence that a physician order was obtained immediately following all restraint applications. Review of the “Restraint Flow sheet” revealed on 11/19/2025 Patient ID #1 was restrained at the following times: - 8:55 AM - 9:10 AM - 9:39 AM - 4:49 PM - 8:25 PM Further record review revealed that the following orders were obtained for restraints for Patient ID #1 on 11/19/2025 however, the times listed on the restraint flow sheet do not align with the physician orders. - At 11:08 AM, One person stability hold and a one person stability hold with legs - At 11:17 AM, One person stability hold with legs - At 11:21 AM, Locked seclusion in quiet room - At 7:23 PM, One person stability and three person supine - At 9:05 PM, One person with legs to three-person supine 2. Record review revealed that Patient ID #2 was admitted to the hospital in September of 2025 with a diagnosis including, but not limited to, adjustment disorder with mixed disturbance of emotion and conduct. Review of the “Restraint Flow sheet” revealed on 1/2/2026 Patient ID #2 was restrained at 10:35 AM. Record review revealed that an order was obtained for restraints for Patient ID #2 on 1/2/2026 at 11:06 AM, for a one-person stability hold. The patient’s medical record failed to reveal evidence that a physician order was obtained immediately following all restraint applications. During a surveyor interview on 2/17/2026 at approximately 8:45 AM, with the Risk Manager, she confirmed that the orders for the restraints on 11/19/2025 and 1/2/2026 were not obtained during the emergency application of the restraint or immediately following application.”