Eleanor Slater 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: 30526 Based on observations from hospital video surveillance, medical record review, and staff interviews, it was determined that the hospital failed to provide care in a safe setting and failed to ensure a safe environment for 1 of 2 patients who eloped from the hospital (Patient ID #2), by failing to maintain control and security of unit keys on a secured psychiatric unit, thereby allowing patient access to the keys and unauthorized exit from the unit and hospital. Findings include: Review of the hospital policy titled “Patient Safety Monitoring Levels,” effective 1/14/2026, stated in part: Patient Safety Level Assignments / Levels of Observation Level A: Patients are unsupervised when off the unit. Level B: Patients must always be supervised by a staff member while off the unit. Level C: Patients are restricted to the unit. Review of the medical record for Patient ID #2 revealed a date of birth of 2/13/1967. The patient was readmitted to the hospital on 3/21/2025 with a primary diagnosis of schizoaffective disorder, bipolar type. The patient resided on a secured unit and was assigned a Level B observation status per physician orders dated 5/5/2026. The patient was identified as high risk for elopement. Review of surveillance video dated 5/8/2026 revealed that at approximately 5:17 PM, Staff A, who was assigned to provide constant observation, was observed walking in the hallway with the assigned patient. Staff A unlocked the bathroom door and entered the bathroom with the assigned patient, leaving the keys hanging in the bathroom door lock. Staff A subsequently exited the bathroom with the patient and proceeded to the patient ’ s room leaving the keys in the bathroom door. Video surveillance further revealed that Patient ID #2 walked past the bathroom door multiple times while the keys remained in the lock. Two additional staff members were also observed walking past the bathroom door while the keys remained unattended in the lock but failed to notice the keys. At approximately 5:41 PM, Patient ID #2 was observed walking in the hallway wearing a hat and coat, approaching the bathroom door, removing the keys from the bathroom door lock, and proceeding to the unit exit door. Surveillance footage showed Patient ID #2 manipulating the keys for approximately one minute before successfully unlocking the exit door at approximately 5:42 PM and exiting the secured unit. Surveillance footage further showed Patient ID #2 exiting the building at approximately 5:45 PM. During a telephone interview conducted by the surveyor on 5/19/2026 at approximately 1:15 PM, in the presence of Risk Manager Staff C, IAP Staff A stated that Staff A took the assigned patient to the bathroom and left the keys on the bathroom counter. Staff A stated that while assisting the patient in the bathroom stall, Patient ID #2 entered the bathroom and took the keys. Staff A stated the removal of the keys was not observed because assistance was being provided to the assigned patient in the stall. Staff A further stated the keys were not identified as missing until the assigned patient later requested to return to the bathroom and the keys could not be located. During an interview on 5/19/2026 at approximately 1:30 PM with the surveyor , Risk Manager Staff C stated that Staff A left assigned keys and identification badge in the bathroom door and that this was confirmed on surveillance video. Risk Manager Staff C further stated that the surveillance footage showed Patient ID #2 noticing the keys, returning to the patient room, reappearing with a hat and coat, removing the keys from the door, unlocking the exit door, and exiting the building. Exterior surveillance footage later showed Patient ID #2 crossing the street in front of the building and entering the parking lot of the building across the street. When asked how staff working on the unit failed to observe either the unattended keys or Patient ID #2 exiting the unit, Risk Manager Staff C stated that all staff assigned to the unit at the time were interviewed. Staff members who walked past the bathroom door stated the keys were not noticed. Staff assigned to monitor patients in the common area stated the exit door was not visible from assigned seating locations. During an interview with the surveyor on 5/19/2026 at approximately 2:45 PM, the Assistant Director of Nursing (ADON), Staff E, stated that all staff assigned to the AM building are issued a master key upon hire that opens both unit doors and bathroom doors. Staff E stated that staff are instructed to keep keys secured on staff person at all times, never leave keys unattended, and never allow another staff member to use assigned keys. Staff E further stated that standard practice on psychiatric security units requires staff to maintain continuous control of assigned keys and ensure patients do not gain access to them. The hospital failed to provide care in a safe setting for a patient identified as high risk for elopement by failing to ensure staff maintained control and security of unit keys on a secured psychiatric unit. This failure allowed Patient ID #2 to gain access to the keys, unlock the secured unit exit door, elope from the unit, and subsequently exit the hospital building unnoticed.”

“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: 30526 Based on observations from hospital video surveillance, medical record review, and staff interviews, it was determined that the hospital failed to follow accepted standards of practice related to securing unit keys, preventing patient access to keys on a secured unit for 1 of 2 patients who eloped from the hospital (Patient ID #2). Findings are as follows: Review of the hospital policy titled “Patient Safety Monitoring Levels,” effective 1/14/2026, revealed the following patient safety level assignments and observation requirements: Level A: Patients are unsupervised when off the unit. Level B: Patients must always be supervised by a staff member while off the unit. Level C: Patients are restricted to the unit. Review of the medical record for Patient ID #2 revealed a date of birth of 2/13/1967. The patient was readmitted to the hospital on 3/21/2025 with a primary diagnosis of schizoaffective disorder, bipolar type. Record review further revealed that the patient resided on a secured unit and was assigned a “Level B” observation status per physician orders dated 5/5/2026. The patient was also identified as high risk for elopement. Review of surveillance video footage dated 5/8/2026 revealed that at approximately 5:17 PM, IAP (Institutional Attendant Psychiatric) Staff A was observed walking in the hallway with a patient assigned for constant observation. Staff A unlocked the bathroom door and entered the bathroom with the assigned patient, leaving the keys in the bathroom door lock. Staff A subsequently exited the bathroom with the assigned patient and proceeded to the patient ’ s room. Video surveillance further revealed that Patient ID #2 walked past the bathroom door multiple times while the keys remained hanging in the lock. Two additional staff members were also observed walking past the bathroom door without noticing the keys. Patient ID #2 was later observed walking to the patient ’ s room. At approximately 5:41 PM, Patient ID #2 was observed exiting the room wearing a hat and coat, approaching the bathroom door, removing the keys from the lock, and walking to the unit exit door. After manipulating the keys for approximately one minute, Patient ID #2 successfully unlocked the exit door at approximately 5:42 PM and exited the unit without staff intervention or observation. Surveillance footage further revealed that Patient ID #2 exited the building at approximately 5:45 PM. During a telephone interview conducted by the surveyor on 5/19/2026 at approximately 1:15 PM, in the presence of Risk Manager Staff C, IAP Staff A stated that Staff A had taken the assigned patient to the bathroom and left the keys on the bathroom counter. Staff A stated that while assisting the patient in the bathroom stall, Patient ID #2 entered the bathroom and took the keys. Staff A stated Staff A did not observe Patient ID #2 take the keys because Staff A was assisting another patient. Staff A further stated that Staff A did not realize the keys were missing until the assigned patient later requested to return to the bathroom and the keys could not be located. During an interview with the surveyor on 5/19/2026 at approximately 1:30 PM, Risk Manager Staff C stated that Staff A left assigned keys and identification badge in the bathroom door, as confirmed by surveillance video. Staff C further stated that the surveillance footage showed Patient ID #2 noticing the keys, returning to the room to put on a hat and coat, retrieving the keys, unlocking the exit door, and exiting the building. Staff C additionally stated that exterior surveillance footage later showed Patient ID #2 crossing the street in front of the building and entering the parking lot of a building across the street. When asked how staff failed to observe either the keys left in the door or Patient ID #2 exiting the unit, Risk Manager Staff C stated that all staff working on the unit at the time of the incident were interviewed. Staff members who walked past the bathroom door stated the keys were not noticed. Staff assigned to the common area reported the exit door could not be visualized from assigned seating locations. During an interview with the surveyor on 5/19/2026 at approximately 2:45 PM, Assistant Director of Nursing (ADON) Staff E stated that all staff assigned to the AM building are issued master keys upon hire, which provide access to both unit doors and bathroom doors. Staff E stated that staff are instructed to keep keys secured on staff person at all times, never leave keys unattended, and never permit another staff member to use assigned keys. Staff E further stated that standard practice on psychiatric security units requires staff to maintain continuous control of assigned keys and ensure that patients do not gain access to them. The hospital failed to ensure that accepted standards of practice were maintained for a patient identified as high risk for elopement by failing to ensure staff secured assigned keys, which allowed Patient ID #2 to obtain the keys, unlock the unit exit door, exit the secured unit, and subsequently leave the building unnoticed.”

“DETERMINATIONS OF MEDICAL NECESSITY CFR(s): 482.30(d) (1) The determination that an admission or continued stay is not medically necessary- (i) May be made by one member of the UR committee if the practitioner or practitioners responsible for the care of the patient, as specified in §482.12(c), concur with the determination or fail to present their views when afforded the opportunity; and (ii) Must be made by at least two members of the UR committee in all other cases. (2) Before making a determination that an admission or continued stay is not medically necessary, the UR committee must consult the practitioner or practitioners responsible for the care of the patient, as specified in §482.12(c), and afford the practitioner or practitioners the opportunity to present their views. (3) If the committee decides that admission to or continued stay in the hospital is not medically necessary, written notification must be given, no later than 2 days after the determination, to the hospital, the patient, and the practitioner or practitioners responsible for the care of the patient, as specified in §482.12(c). This Standard is not met as evidenced by: 32374 Based on record reviews and staff interviews, the hospital failed to ensure that patients were provided with written notification within two days after the determination was made that their continued stay was no longer medically necessary, for 5 of 5 patient records reviewed, (Patient ID #s 1, 2, 19, 20, and 21). Findings are as follows: Record review revealed Patient ID #1 was admitted to the Long Term Acute Care (LTAC) Hospital on 10/18/2024. On 1/16/2025, it was determined that s/he no longer met LTAC level of care. Further review failed to reveal evidence that the patient or his/her representative received written notice that the patient no longer qualified for LTAC level of care. Record review revealed Patient ID #2 was admitted to the LTAC on 4/2/2025. On 5/8/2025, it was determined that s/he no longer met LTAC level of care. Further review failed to reveal evidence that the patient or his/her representative received written notice that the patient no longer qualified for LTAC level of care. Record review revealed Patient ID #19 was admitted to the LTAC on 9/22/2025. On 10/29/2025, it was determined that s/he no longer met LTAC level of care. Further review failed to reveal evidence that the patient or his/her representative received written notice that the patient no longer qualified for LTAC level of care. Record review revealed Patient ID #20 was admitted to the LTAC on 5/28/2024. On 10/10/2024, it was determined that s/he no longer met LTAC level of care. Further review failed to reveal evidence that the patient or his/her representative received written notice that the patient no longer qualified for LTAC level of care. Record review revealed Patient ID #21: Admitted 1/28/2025. On 3/17/2025, it was determined that s/he no longer met LTAC level of care. Further review failed to reveal evidence that the patient or his/her representative received written notice that the patient no longer qualified for LTAC level of care. During a surveyor interview on 3/12/2026 at 10:15 AM, with the Associate Director who oversees the hospital’s Utilization Review, they were unable to provide evidence that the hospital notified Patient ID #s 1, 2, 19, 20, and 21or their representatives when the determination was made that an admission or continued stay in the LTAC hospital setting was not medically necessary.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 32374 Based on record review and staff interviews, it has been determined that the hospital failed to re-evaluate patients’ conditions to identify changes that require the modification or updates to their discharge plans, for 4 of 5 patients reviewed, (Patient ID #s 1, 2, 19, and 21). Findings are as follows: 1. Record review revealed that Patient ID #1 was admitted to the Long-Term Acute Care (LTAC) hospital on 10/18/2024 and was evaluated to no longer meet LTAC level of care as of June 2025. The patient was hospitalized in an acute care hospital in December of 2025. S/he was readmitted to the LTAC upon discharge. The patient was noted to have met LTAC level of care criteria for approximately 8 days, until 1/15/2026. Additional record review revealed the Social Worker (SW) had sent referrals for the patient’s transfer to75 skilled nursing facilities (SNF) in June of 2025, without any acceptance from any of the SNFs. In July of 2025, The SW sent 10 SNFs referrals for the patient and received no acceptances. Further record review failed to reveal evidence that any discharge referrals were made since July of 2025. 2. Record review revealed that Patient ID #2 was admitted to the LTAC hospital on 4/2/2025. The patient was evaluated to no longer meet LTAC level of care as of 5/8/2025. Long Term Specialized Services (LTSS) financing was approved in September of 2025. Additional record review revealed that the SW documented that they planned to contact 75 SNFs in September to place the patient since his/her status was downgraded from the LTAC level of care. Further record review failed to reveal evidence that any referrals were sent out prior to December 2025. Furthermore, none of the SNFs agreed to accept the patient from the referrals that were made in December. In February 2026 the patient was transferred to an acute care hospital for medical concerns and was admitted. On 2/28/2026 the medical hospital attempted to discharge the patient back to the LTAC and was denied readmission to the LTAC. During an interview with the Associate Director on 3/12/2026 at approximately 11:00 AM, she was unaware that ongoing referrals for discharge to an appropriate level of care had not been made since December 2025 until the patient medical admission in February. 3. Record review revealed that Patient ID #19 was admitted to the LTAC hospital on 9/22/2025 and was evaluated to no longer meet LTAC level of care as of June 10/29/2025. The patient was sent emergently to an acute care hospital on 12/6/2025. Although the SW documented LTSS application and the patient ‘s preference for a SNF or home with services, no placement referrals were made between 10/29/2025 and the patients discharge to the acute care hospital on 12/7/2025. During an interview with the Associate Director on 3/12/2026 at approximately 11:00 AM, she was unable to explain why discharge to an appropriate level of care was not pursued for Patient ID #19. 4. Record review revealed that Patient ID #21 was admitted to the LTAC hospital on 1/28/2025 and was evaluated to no longer meet LTAC level of care as of 3/17/2025. Acute rehab facilities were contacted in April of 2025, but the patient refused to go. The SW referred the patient to 26 SNFs in May of 2025, and a bed was initially located for the patient who had a tracheostomy (a tracheostomy is a surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised), which Patient ID #21 had in place. However, in July of 2025 the patient was decannulated (the process of removing a tracheostomy tube when it is no longer needed for breathing), which disqualified him/her from being eligible for that bed. In November of 2025, the patient was accepted to an Assisted Living Facility and would be eligible for admission, when a bed became available. During surveyor interview with the SW on March 9, 2026, at approximately 10:50 AM, she acknowledged that she had not pursued any other facilities since November of 2025 because Patient ID #21 was pending admission to an Assisted Living facility once a bed was available. During an interview with the Associate Director on 3/12/2026 at approximately 11:00 AM, she revealed that she was unaware that SW did not continue to look for placement for Patient ID #21.”

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 32374 Based on record review and staff interviews, it has been determined that the hospital failed to assess its discharge planning process on a regular basis. Findings are as follows: The hospital’s Admission, Discharge, and Transfer Policy (dated 6/21/2022) does not include procedures for assessing the discharge planning process. The hospital’s Utilization Review Plan (dated 10/26/2023) specifies that the Utilization Review (UR) Committee will review admissions, lengths of stay, extended stays, and professional services, but does not address regular assessment of discharge planning. The Associate Director overseeing Discharge Planning and Utilization Review was interviewed on 3/12/2026 at 1:40 PM and was unable to provide evidence that discharge planning is regularly reviewed or assessed. She could not provide evidence of records reviewed, including for patients readmitted within 30 days, to ensure discharge plans were responsive to post-discharge needs. The Associate Director acknowledged that these reviews are not being conducted and indicated that the hospital plans to create a new Case Manager position to oversee Discharge Planning and Utilization Review.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 32374 Based on record reviews and staff interviews, it has been determined that the hospital failed to ensure that appropriate post-hospitalization arrangements were made prior to discharge for 1 of 2 patients reviewed (Patient ID # 1) who had an unnecessary delay in seeking discharge placement. Findings are as follows: 1. Patient ID #1’s record review revealed the following: The patient was admitted to the Long Term Acute Care (LTAC) hospital in October 2024 and was determined to no longer meet LTAC level of care as of June 2025. Patient ID #1 was hospitalized in an acute care hospital in December of 2025. S/he was readmitted to the LTAC upon discharge. The patient was noted to have met LTAC level of care criteria for approximately 8 days, until 1/15/2026. A review of the Care Plan for Patient ID #1, dated 1/15/2026, indicated that the Social Worker had referred the patient to 75 Skilled Nursing Facilities (SNF) in June 2025 and reported received no admission acceptances. Another referral was made in July 2025 also with no admission acceptance offers. During an interview on 3/5/2026 at 3:30 PM, with the Chief Medical Officer, she was not aware that discharge referrals had not been made since July of 2025.”

“DISCHARGE PLANNING-D/C PLANNING LIST CFR(s): [The hospital must] include the discharge planning a list of HHA’s, SNF’s, IRF’s, or LTCH’s that are available to the patient, that are participating in the Medicare program, and that serve the geographic area(as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available. (i) The list must only be presented to patients for whom home health care post hospital extended care services, SNF, IRF, or LTCH services are indicated and appropriate as determined by the discharge planning evaluation. (ii) For patients enrolled in managed care organizations, the hospital must make the patient aware of the need to verify with their managed care organization which practitioners, providers or certified suppliers are in the network of the patient’s managed care organization, it must share this with the patient or the patient’s representative. (iii) [The hospital must] document in the patient’s medical record that the list was presented to the patient or to the patient’s representative.…. This Standard is not met as evidenced by: 32374 Based on record review and staff interview, it has been determined that the hospital’s discharge planning failed to provide patients with a list of Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), or Inpatient Rehabilitation Facilities (IRFs) when eligible for discharge and requiring home services or a lower level of care. Findings area as follows: Record review for Patient ID #’s 1, 2, 19, 20, and 21, all of whom had discharge evaluations and were no longer LTAC level of care, failed to reveal evidence that these patients were given a list of agencies or facilities as part of discharge planning. The records also lacked documentation that such a list was provided, as required by regulation. During a surveyor interview on 3/12/2026 at 11:30 AM, the Associate Director was unable to provide evidence that the hospital maintains or distributes a list of agencies/facilities to patients or their representatives. She stated that Social Workers maintain a list but acknowledged that copies are not provided to patients and that there is no documentation in the patient records confirming that a list of choices was given.”

“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 and staff interviews it has been determined that the hospital failed to follow the hospital’s policy titled “Patient Supervision Levels Policy and Patient Supervision Levels Procedure” revised on 7/2023, for 1 of 3 patients, Patient ID #1 who went outside unsupervised by staff in a motorized wheelchair and sustained an injury. Findings are as follows: Review of the hospital’s policy and procedure titled “Patient Supervision Levels Policy & Procedures” states in part, “Policy 1. Supervision levels ordered for patients represent the extent of routine liberty assigned to each patient ... Supervision Level B- Patients are always supervised ... The patient does not have the ability to care for self... B. Procedure ... 7. b Supervision level B: The patient may leave the unit with supervision. The provider will write the order for this level, the number and discipline of those accompanying the patient the destination, and time allowed off the unit.” Record review for Patient ID#1 revealed the patient was admitted on 3/27/2025. The patient is not ambulatory and uses a Hoyer lift for all transfers. S/he uses a motorized wheelchair for mobility and is a supervision level B status which requires a patient to be “always supervised”. On 7/26/2025 the patient went outdoors in his/her motorized wheelchair without staff supervision and was injured. A review of Patient ID #1’s physician orders dated 7/16/2025 identified the following orders: “activity OOB no more than 1 hour each time BID (twice a day), ...may attend therapeutic recreation and off unit activity”. A review of the hospitals the “Off Unit Leave Monitoring Sheet” dated 7/26/2025 identified the following: Patient ID #1 was signed out of the building at 1:40 PM and returned to the hospital at 2:35 PM. The monitoring sheet identified the patient was “outside”. A review of the hospital’s surveillance video of the patient exiting and re-entering the hospital for 7/26/2025, revealed the following: -Patient ID #1 at 1:35 PM exiting the hospital in a motorized wheelchair accompanied by a family member. The patient was noted to be wearing prevalon protective pressure relief boots on both feet. -At 2:36 PM the patient returned inside the hospital and is observed in the elevator. The prevalon protective boots are noted only attached to the patients lower legs and not around the patients feet as they are intended. The wheelchair appeared to be stuck, and blood was noted on the floor below the chair. A Nurse, Staff F is observed on the video trying to assist the patient, Nurse, Staff G enters the elevator, and the two nurses are noted to tilt the chair back, and a nursing assistant was able to release the patient’s injured foot from under the chairs footrest where it was noted to be trapped. During an interview with Nurse, Staff F on 8/27/2025 at 3:45 PM, he stated he saw the patient’s spouse bending down in front of chair and asked if they needed help. He said there was a considerable amount of blood on the floor, but he couldn’t see where it was coming from. He said he called for the doctor who responded. After physician examination, the patient was emergently sent to Rhode Island Hospital via EMS. During an interview with the Risk Manager, Staff B on 8/28/2025 at 11:45 AM, he was unable to explain why the patient was allowed to go outside without staff supervision as required and could not produce evidence that the hospitals policy related to patient supervision was followed.”

“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: 30526 32374 Based on record review, and staff interviews, the hospital failed to ensure a patient’s right to receive care in a safe setting was upheld during a patient transfer with the use of a mechanical lift, when a patient fell from the lift pad to the floor and sustained a head laceration during a transfer, for 1 of 1 patient reviewed, (Patient ID #1). Findings are as follows: Review of a nursing progress note dated 7/18/2025 at 4:00 PM, revealed that Staff A screamed for help because Patient ID #1 had slid off the mechanical lift pad during a transfer from a chair to bed. The patient hit his/her head during the fall and sustained a laceration. During an interview on 7/22/2025 at 11:40 AM, with Patient ID #1, s/he stated that they had told the staff not to cross the leg straps of the lift pad because it hurts their left leg. S/he said the staff did not cross the straps on the pad, and staff lifted him/her up and s/he slipped out of the pad onto the floor. During an interview on 7/22/2025 at approximately 3:40 PM, with the certified nurse assistant’s (CNA) Staff A, and (CNA) Staff B who were both transferring the patient at the time of the fall. Staff A stated that the patient asked to go back to bed, she asked Staff B to assist her. Patient ID #1 was seated in his/her wheelchair on a lift pad. Staff A stated that when she started to cross the leg straps of the “crisscross pad”, the patient said, “don’t cross them they hurt my left leg”. She stated she did not cross the leg straps. As the patient was raised up in the lift, s/he slid out onto the floor. During an interview on 7/22/2025 at approximately 3:40 PM with (CNA) Staff B, She stated that the patient just slid right out of the lift pad as s/he was lifted off the chair. During an interview with the Nurse, Staff D, on 7/22/2025 at approximately 2:30 PM, she stated that hospital should be using the “sling pads” for mechanical lift transfers, and was unaware that the staff were using the “crisscross pads” to transfer patients.”

“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, surveyor observation and staff interviews, it has been determined that the hospital failed to provide nursing care in accordance with accepted standards of nursing practice, and hospital policies relative to the transfer of patients via a mechanical lift for 1 of 1 patient reviewed who slid off of the lift pad during a transfer, Patient ID #1. Findings are as follows: Review of the hospitals “Safe Patient Handling Procedure” states in part: “Reassessment: B: Daily Safe Patient Handling and Movement Considerations: 4. Use mechanical lifting devices and other approved patient handling aids in accordance with instructions and training. During an interview on 7/22/2025 at approximately 3:40 PM, with the certified nurse assistant (CNA) Staff A, she stated that when preparing the patient for the transfer back to bed, she attempted to cross the leg straps of the “crisscross pad”. The patient stated, “don’t cross them...”. The CNA did not cross the leg straps as required and the patient slid from the lift pad onto the floor. During an interview with the Nurse Educator, Staff D, on 7/22/2025 at approximately 2:30 PM, she stated that the lift pads have manufacturer labels on them that show a diagram of how to use the pad. She stated that she spoke with Staff A, who acknowledged that she did not follow the instructions for use of the “crisscross pad”.”

“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: 30526 Based on review of hospital policies, and staff interviews, it has been determined that the hospital failed to provide a safe environment and have mechanisms/methods in place that ensure patients are protected from of all forms of abuse and neglect, including injuries of unknown origin, as evidenced by the failure to protect 1 of 1 patient reviewed who was found to have a fractured tibia and fibula of unknown origin, Patient ID # 1. Findings are as follows: Review of the hospital’s policy entitled, “Abuse and Neglect-Guidelines for Screening and Intervention,” which was last approved on 3/2022 states in part, “II. POLICY: ... 2. All staff at the [Eleanor Slater Hospital] ESH are responsible to report actual or suspected cases of abuse and/or neglect. The hospital is responsible to evaluate all allegations, observations and suspected cases of neglect, exploitation, and abuse. 3. Staff suspecting abuse or neglect must report suspicions to his/her supervisor. The supervisor is responsible for initiating appropriate actions including notifying his/her supervisor and administration. Review of the hospital policy titled “Patient Rights and Responsibilities” policy, last approved on 3/2022, states, in part, IV: Policy Statement Pertaining to Patients’ Rights 1. The patient shall be treated with dignity and respect, [and] afforded considerate and respectful care ... 19. The patient has the right to be free from neglect, exploitation, verbal, mental, physical, and sexual abuse...” Review of the record for Patient ID #1, revealed that s/he was admitted to the hospital in 1999, and has diagnoses which includes infantile autism with profound developmental delay, insulin dependent diabetes with suspected neuropathy, seizure disorder, vitamin D deficiency, obesity, and persistent bilateral lower extremity edema. Additional record review reveals s/he has ongoing issues with fluid retention (edema), swelling in various parts of his/her body. The patient is non-verbal and only has the ability to move his/her upper extremities on a very limited basis and is unable move his/her lower extremities. The patient requires total assistance with all personal care, ADLs including repositioning in bed, feeding, and incontinence care. Review of the Physician orders reveals an order for Ted’s (anti-embolic) stockings. Review of the patients Plan of Care states Ted’s are applied in the morning and removed every night with hygiene care. According to documentation, on 12/28/2024 during the 11PM -7AM shift, the Nursing Assistant, Staff A, while providing care to the patient, at approximately 2:20 AM, staff noticed the right ankle swollen with a protrusion. Staff A and Nursing Assistant, Staff E informed the Nurse, Staff F who notified the On-Call Physician. The On-Call Physician came in to assess the patient. Review of the ESH On-Call Physician’s note dated 12/28/2024 at 3:15 AM, stated staff had reported the area of redness and “protrusion” to his/her lateral right ankle. The progress note stated there was swelling for the past month and indicated “Right ankle swelling and edema, possible deformity, small soft red to lateral right malleolus. Concern for possible subacute fracture to ankle, x-ray ordered in the AM.” On 12/29/2024 at 10:50 AM the patient was transferred to Landmark Medical Center for further evaluation of the right ankle. A review of the medical records from Landmark Medical Center dated 12/28/2024 revealed “the patient has a confirmed fracture of the distal tibia and fibula, which was confirmed by x-ray. The record indicates “the facility has no idea as to what happened to the patient.” The x-ray report reveals the patient had a closed fracture of distal tibia and fibula, “concern is that the distal fibular is likely osteoporotic, causing deterioration to the medial malleolus, possible pathological fracture however mechanical fracture seems to be more consistent.” During an interview with Eleanor Slater Hospital Nursing Assistant, Staff I, on 1/6/2025 at 9:50 AM, she stated that she worked on 12/27/2024 and that at 7:00 PM she and another nursing assistant put the patient back to bed. She removed the Ted’s stockings, and noticed the patient had some swelling, but nothing different than what s/he has been having for quite a while. She stated there was no protrusion or deformity noted at that time. During an interview with ESH Staff A, at 3:15 PM on 1/6/2025, who had worked on 12/28/2024, the 11-7 AM shift, stated that when she went in to do rounds around 2:00 AM, that the patient’s pressure relief boot was on the floor. She looked at the patient’s ankle and noticed a swollen area that looked like bone. She asked the other nursing assistant to look at it and they went and reported it to the Nurse, Staff F. She informed the surveyor that staff had been having trouble putting on the patient’s Ted’s stockings due to the edema. She stated that this was reported this to the Nurses, but because they had a doctor’s order, the patient needed to have the Ted’s on. During an interview with ESH Nurse Manager, Staff J, on 1/6/2025 at approximately 11:30 AM, stated that she was aware of the patient having an order for the Ted stocking and that she had obtained an order to discontinue them on 12/31/2024 at 12:00 PM, after the patient was diagnosed with a fracture. She acknowledged they are difficult to put on when patients have edema. During an interview with the ESH Risk Manager on 1/7/2025 at approximately 11:15 AM. she stated that when she initially reported the incident to the Rhode Island Department of Health, She acknowledged that she had not directly interviewed staff, but states she had collected statements from multiple staff all of which denied knowledge of the injury, or how a patient may have sustained the injury. During an interview with the ESH Podiatrist who had seen the patient on 1/7/2025 at 10:30 AM and had reviewed the Landmark Hospital Emergency Department report and stated he believes that the patient sustained some sort of injury, since there are two fractures, both a tibia and a fibula fracture.”

“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 medical records, review of facility documents, and Staff interviews, it was determined that the Hospital failed to meet the Condition of Participation: Nursing Services after the following was identified: -The Registered Nurse failed to re-assess a patient prior to a determining a patients need to be transferred to the hospital. (A-0395) -Failure to notify the Physician regarding the patient’s deteriorating condition, which resulted in the patient becoming unresponsive, requiring CPR, and transfer to the hospital. (A-0386) -The Nurse failed to report to the oncoming Nurse the patient’s recent change in condition during hand-off communication. (A-0386) -The Institutional Psychiatric Attendants (IAP) failed to conduct hand-off communication with the oncoming IAP. (A-0386) These failures resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment or death to all patients. Findings are as follows: A CMS authorized Substantial Allegation Survey was conducted from 9/12/2024 through 9/18/2024 at Eleanor Slater Hospital to determine compliance with the Condition of Participation for hospitals: 482.23 Nursing Services following an anonymous report alleging that a patient died due to a potential bowel obstruction. On 9/16/2024 a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR 482.23 A-0385 Condition of Participation: Nursing Services, related to the Nursing Supervisor’s failure to assess the patient prior to deciding not to transfer the patient to the hospital after the Physician and the unit Nurse discussed the patients condition and the physician and a verbal agreement was made to transfer the patient to an acute care hospital for an evaluation. The Nursing Supervisor deemed the patient’s medical transfer was “unwarranted,” claiming the patient was not in distress and only constipated. Additionally, the Nurse, Employee C, failed to notify the physician of the patient’s status and recent change in condition, which resulted in the patient to become unresponsive, subsequently requiring CPR, and to be emergently transferred to the acute care hospital. The hospital’s Risk Manager and Chief Nursing Officer were informed of the Immediate Jeopardy, which was identified on 9/16/2024 and were provided with the Immediate Jeopardy template at approximately 2:40 PM on this date. On 9/17/2024 the hospital submitted the 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: - Revision of the nursing policy on hand-off communication to include a provision for escalation of care in the chain of command. - All clinical staff will be educated on the hand-off communication policy and attest their understanding of the expectations on immediately reporting any changes in a patient’s clinical presentation or symptoms of distress and the provisions for escalation of care. - Nursing staff will attest to the receipt of this education and policy review prior to providing any patient care. On 9/18/2024 an audit was completed by the state surveyors and the IPOC was verified as being fully implemented by verifying policy changes, review of education provided, and interviews with staff who received the education. As of 9/18/2024 the IJ was removed.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 32374 Based on record review and staff interview, it has been determined the hospital failed to ensure that licensed nurses who provide services in the hospital adhere to the policies and procedures of the hospital for 1 of 1 patient reviewed who experienced a change in condition and required an emergent transfer to an acute care hospital. Findings are as follows: The hospital’s policy titled; “Hand-Off Communication” last reviewed in September of 2020 states in part: “...Hand-off is defined as the provision of verbal and/or written information from one healthcare provider to another so that care, treatment needs as well as the patient’s current condition and any recent or anticipated changes are accurately communicated... Policy... ...Shift reports from the nurse to the nurse and from the nurse to the nursing assistant and from the nursing assistant to the nurse... Change of Shift report from the nursing assistant to the nursing assistant... Nurse to Physician... 3. Hand-off communication shall include pertinent up-to-date information regarding the patient’s treatment, care, and services, as well as current status and any recent changes or anticipated changes in the patient’s condition ...” Record review for Patient ID #1 revealed she/he was admitted to the hospital in July of 2024 following an admission to another hospital due to worsening psychosis with agitation and disorganized behavior. His/her diagnoses include, but are not limited to, schizoaffective disorder and intellectual disability. Record review revealed that on 9/6/2024 during the 7:00 AM through 3:00 PM shift, Patient ID #1 complained of stomach pain, stated she/he had not moved his/her bowels in 3 to 4 days and had vomited. At 1:00 PM on 9/6/2024, the Physician, Employee A, indicated in the record that he evaluated the patient and identified that she/he had “diffuse tenderness” to his/her abdomen, “denied passing gas, had positive bowel sounds on all quadrants of the abdomen and had no signs of rebound.” The Physician then concluded that the patient was experiencing constipation and ordered a clear liquid diet for 24 hours, Miralax, a laxative solution, with prune juice, and lactulose, a laxative. The Nurse, Employee B, then administered these orders to the patient at 1:15 PM. According to Employee B, the patient reported she/he vomited twice after taking the Miralax, prune juice, and lactulose. Staff B also reported the patient refused an additional dose of Miralax and prune juice when they were offered again at 3:15 PM because she/he had vomited. Record review revealed a nursing note dated 9/6/2024 at 8:40 PM, in which the Nurse, Employee C, stated that Patient ID #1 was complaining of constipation and the last dose of Miralax, and prune juice were administered. She described the patient as “irritable” and indicated that the patient stated she/he was full. Employee C stated in her note that the patient’s stomach was “distended,” she/he had positive bowel sounds and had denied she/he vomited or felt nauseous. Employee C further revealed in her note that earlier in the evening, at 7:40 PM, Patient ID #1 received a fleet enema, a medication used for constipation, via his/her rectum and she/he tried to move his/her bowels but was unsuccessful and sat on the bathroom floor for 15 minutes before returning to his/her room. Employee C stated that she then obtained an order for Magnesium Citrate, a laxative solution, but the patient only ingested a quarter of the bottle and yelled at her, “I am full!” Record review of a progress note dated 9/7/2024 at 1:45 AM completed by the on-call Psychiatrist, Employee D, revealed that at 9:54 PM on 9/6/2024, she was told by telephone that Patient ID #1 had not moved his/her bowels, was refusing to drink liquids, was irritable, and swearing at the nurse and a discussion about sending the patient to the emergency room took place. At 10:04 PM according to the on-call Psychiatrist’s timeline which was provided by the on-call Psychiatrist from her cell phone, Employee C had reported that the Nursing Supervisor did not feel that the emergency room visit was warranted. The record failed to reveal evidence that the Supervising Nurse, Employee F, re-evaluated the patient prior to making this decision. Further review of nursing progress notes revealed that at 10:30 PM on 9/6/2024, Employee C stated that Patient ID #1, “continued to be irritable” and lied down on the floor three times during the shift “complaining of stomach discomfort” and refused to drink fluids but described him/her as “not in distress.” Additionally, Employee C stated that the patient’s bowel sounds were, “sluggish” on both sides of the lower abdomen. At 11:00 PM, Employee C stated in her note that Patient ID #1’s abdomen was distended and she/he “took a sip of water,” and refused the rest of the Magnesium Citrate. She indicated that the Psychiatrist on-call, Employee D, was informed but did not provide new orders during a “previous call.” Employee C, indicated in her note that she informed the on-call Psychiatrist, however evidence provided by the psychiatrist revealed that the last call by Employee C was at 10:04 PM. The next call that she received was at 12:55 AM, by Employee E stating that 911 had been called for Patient ID #1. Record review of a nursing note dated 9/7/2024 at 2:30 AM completed by the Nurse, Employee E, revealed that at 12:55 AM on this date, Patient ID #1 complained of abdominal pain, his/her stomach was visibly distended, she/he placed himself/herself on the floor and was “unable to stay still.” Employee E stated that Patient ID #1 returned to his/her room after this episode and she returned to the nurses’ station to call the Supervising Nurse, and the Psychiatrist on-call who gave the order to transfer the patient to the hospital. Employee E revealed in her note that while on the phone with 911, a staff member “ran to the nursing station” to inform her and the Supervising Nurse, who was now on the unit and at the nurses’ station, that Patient ID #1 vomited a large amount of “dark liquid” and was “unresponsive.” Employee E further stated in her note that a code blue was announced, CPR was started, and an Automated External Defibrillator (AED) was placed on the patient. At 1:06 AM, Employee E informed the Psychiatrist On-Call that Patient ID #1 was unconscious. She indicated that the rescue then arrived at 1:12 AM and transferred him/her to the hospital at 1:37 AM. Record review revealed that while in the Emergency Department, Patient ID #1 continued to receive multiple rounds of CPR before the return of spontaneous circulation. The patient was described as having a “rock hard abdomen” and after a surgical consult, an abdominal fasciotomy (a surgical procedure that involves cutting through the connective tissue of the abdomen to relieve pressure) took place at the bedside which revealed the patient had “bowel ischemia (damage caused by a lack of blood supply) and multisystem organ failure.” The record indicated that Patient ID #1 was placed on comfort measures as requested by his/her family and later expired at 1:02 PM on 9/7/2024. During a surveyor interview on 9/16/2024 at 10:48 AM with Institutional Attendant (IAP), Employee G, she stated that on 9/6/2024, she worked second shift and was assigned to a patient on the unit who required one-on-one supervision. She revealed that upon returning to the unit from her break, she was again assigned to the patient who required one-on-one supervision between 8:00 PM and 11:15 PM and was sitting across from Patient ID #1’s room. During this time, Employee G indicated that Patient ID #1 asked to use the bathroom, and she unlocked the door for him/her. She stated that Patient ID #1 was in the bathroom for a while before returning to his/her room. She explained that Patient ID #1 later asked to use the bathroom again, but this time, she observed Patient ID #1 lying on the bathroom floor and another IAP, Employee H, who found him/her said, “Someone needs to call 911.” Employee G states she observed the nurse in the bathroom attempting to give Patient ID #1 a drink, which she/he refused. She indicated that Patient ID #1 then got up from the bathroom floor and laid down in the hallway and the nurse told him/her to return to his/her room, which she/he did. Employee G revealed that she saw Patient ID #1 sitting on his/her bed later in the evening with his/her back against the wall, saying, “Help me, I can’t breathe.” She stated that she had previously reported the patient’s discomfort and his/her “big hard abdomen” to the Nurse Employee C, earlier in the evening, The nurse stated to Employee G, she was aware, and informed Employee G that the patient was constipated. Additionally, she confirmed that she did not provide a change of shift report to the oncoming IAP as required per hospital policy. During a surveyor interview with the evening Supervising Nurse (SRN) Employee F, on 9/12/2024 at 11:30 AM she revealed that after she received her evening supervisor report she later went up to the floor to follow up with Employee C. She then stated that she saw the patient and identified that the patient had a history of constipation and “was not in distress.” Employee F, stated she had received a call from Employee C regarding the transfer of Patient ID #1 to the hospital for further evaluation. She then asked Employee C for the patient’s vital signs, then informed her “How can we send someone out that is not in distress.” She stated she thought the situation could wait until morning because the patient was only constipated. Employee F was then asked if she was aware that Patient ID #1 had vomited, to which she replied, “I was not aware of this,” despite her having access to the shift-to-shift report which indicated the patient had vomited x2 unwitnessed on the day shift. During an additional surveyor interview on 9/16/2024 at 2:35 PM with Employee C, she revealed that SRN, Employee F, did not assess the patient before making the decision to halt the transfer the patient to the hospital because he was “not in distress”. When asked if she was requested by Employee H to call 911 for Patient ID #1 between approximately 9:00 PM to 10:00PM, she replied that she was notified by Employee H and she was told that the patient just vomited. She acknowledged that she saw vomit on the floor, which she described as 15-20 milliliters of an orange saliva type mixture and revealed that she did not mention this to the oncoming Nurse, Employee E, that the patient had an episode of vomiting. Employee C then stated that when her shift ended Patient ID # 1’s abdomen was “slightly distended” and acknowledged that she knew that he/she was uncomfortable. During a surveyor interview on 9/16/2024 at 12:04 PM with Nurse, Employee E, she stated that on 9/6/2024 she started her shift at 11:15 PM and received report from Employee C. When asked what she was told about Patient ID #1 during report, she stated that Employee C told her that the patient had a problem with constipation, and she told her she administered all of the orders provided to her by the doctor. When asked if she was told if the patient vomited, she stated, “I don’t think that there was vomiting on second shift.” She stated that after receiving report, she gave the IAPs report, and checked on the patient through the door, and saw that Patient ID #1 “was sleeping.” She revealed that around 12:55 AM on 9/7/2024, she heard a cry and when she exited the nurses’ station, she saw Patient ID #1 in the hallway “rolling over” and moving and could not obtain an oxygen level because of this and noticed at this time that the patient’s abdomen was “visibly distended.” She indicated that other staff brought the patient to his/her room where she/he later “passed out” after vomiting. During an interview on 9/12/2024 at 12:15 PM with on-call Psychiatrist, Employee D, she stated she was the On-Call Physician and had not received any information on the patient during the Physician handoff report. She revealed she was called three times by the Nurse, Employee C, and at 9:54 PM she received a call from Staff C stating the patient was in discomfort, still had not had a bowel movement and was only taking sips of fluids. Employee D stated that she and Employee C discussed sending the patient out to the Emergency Room for further evaluation and a “verbal agreement was made to send the patient out”. The On Call Psychiatrist then stated that Employee C was asking her questions regarding the process for sending the patient out and she stated that she told Employee C to contact the SRN for the current procedure.”

“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 and staff interview, it has been determined that the hospital failed to ensure the care of a patient was evaluated in accordance with accepted standards of nursing practice for 1 of 1 Supervising Registered Nurse (SRN) who failed to assess a patient prior to determining that he/she did not require transfer to an acute care hospital transfer for further evaluation. SRN, Employee F. Findings are as follows: Record review for Patient ID #1 revealed she/he was admitted to the hospital in July of 2024 following an admission to another hospital due to worsening psychosis with agitation and disorganized behavior. His/her diagnoses include, but are not limited to, schizoaffective disorder and intellectual disability. Record review revealed that on 9/6/2024 during the 7:00 AM through 3:00 PM shift, Patient ID #1 complained of stomach pain, stated she/he had not moved his/her bowels in 3 to 4 days and had vomited. At 1:00 PM on 9/6/2024, the Physician, Employee A, indicated in the record that he evaluated the patient and identified that she/he had “diffuse tenderness” to his/her abdomen, denied passing gas, had positive bowel sounds on all quadrants of the abdomen and had no signs of rebound. The Physician then concluded that the patient was experiencing constipation and ordered a clear liquid diet for 24 hours, Miralax, a laxative solution, with prune juice, and lactulose, a laxative. The Nurse, Employee B, then administered these orders at 1:15 PM. According to Employee B, the patient reported she/he vomited twice after taking the Miralax, prune juice, and lactulose and later refused an additional dose of Miralax and prune juice when they were offered again at 3:15 PM because she/he had vomited. Record review revealed a nursing note dated 9/6/2024 at 8:40 PM, in which the Nurse, Employee C, stated that Patient ID #1 was complaining of constipation and the last dose of Miralax, and prune juice were administered. She described the patient as “irritable” and indicated that the patient stated she/he was full. Employee C stated in her note that the patient’s stomach was “distended,” she/he had positive bowel sounds and had denied she/he vomited or felt nauseous. Employee C further revealed in her note that earlier in the evening, at 7:40 PM, Patient ID #1 received a fleet enema, a medication used for constipation, via his/her rectum and she/he tried to move his/her bowels but was unsuccessful and sat on the bathroom floor for 15 minutes before returning to his/her room. Employee C stated that she then obtained an order for Magnesium Citrate, a laxative solution, but the patient only ingested a quarter of the bottle and yelled at her, “I am full!” Record review of a progress note dated 9/7/2024 at 1:45 AM completed by the on-call Psychiatrist, Employee D, revealed that at 9:54 PM on 9/6/2024, she was told by telephone that Patient ID #1 had not moved his/her bowels, was refusing to drink liquids, was irritable, and swearing at the nurse and a discussion about sending the patient to the emergency room took place. At 10:04 PM according to the on-call Psychiatrist’s timeline which was provided by the Psychiatrist from her cell phone, Employee C had reported that the Nursing Supervisor did not feel that the emergency room visit was warranted. The record failed to reveal evidence that the Supervising Nurse, Employee F, re-evaluated the patient prior to making this decision. Further review of nursing progress notes revealed that at 10:30 PM on 9/6/2024, Employee C stated that Patient ID #1, “continued to be irritable” and lied down on the floor three times during the shift “complaining of stomach discomfort” and refused to drink fluids but described him/her as “not in distress.” Additionally, Employee C stated that the patient’s bowel sounds were, “sluggish” on both sides of the lower abdomen. At 11:00 PM, Employee C stated in her note that Patient ID #1’s abdomen was distended and she/he “took a sip of water,” and refused the rest of the Magnesium Citrate. She indicated that the on-call Psychiatrist, Employee D, was informed but did not provide new orders during a “previous call.” Employee C, indicated in her note that she informed the on-call Psychiatrist, however evidence provided by the psychiatrist revealed that the last call by Employee C was at 10:04 PM. The next call that she received was at 12:55 AM, by Employee E stating that 911 had been called for Patient ID #1. Record review of a nursing note dated 9/7/2024 at 2:30 AM completed by the Nurse, Employee E, revealed that at 12:55 AM on this date, Patient ID #1 complained of abdominal pain, his/her stomach was visibly distended, she/he placed himself/herself on the floor and was “unable to stay still.” Employee E stated that Patient ID #1 returned to his/her room after this episode and she returned to the nurses’ station to call the Supervising Nurse, and the on-call Psychiatrist who gave the order to transfer the patient to the hospital. Employee E revealed in her note that while on the phone with 911, a staff member “ran to the nursing station” to inform her and the Supervising Nurse, who was now on the unit and at the nurses’ station, that Patient ID #1 vomited a large amount of “dark liquid” and was “unresponsive.” Employee E further stated in her note that a code blue was announced, CPR was started, and an Automated External Defibrillator (AED) was placed on the patient. At 1:06 AM, Employee E informed the on-call Psychiatrist that Patient ID #1 was unconscious. She indicated that the rescue then arrived at 1:12 AM and transferred him/her to the hospital at 1:37 AM. Record review revealed that while in the Emergency Department, Patient ID #1 continued to receive multiple rounds of CPR before the return of spontaneous circulation. The patient was described as having a “rock hard abdomen” and after a surgical consult, an abdominal fasciotomy (a surgical procedure that involves cutting through the connective tissue of the abdomen to relieve pressure) took place at the bedside which revealed the patient had “bowel ischemia (damage caused by a lack of blood supply) and multisystem organ failure.” The record indicated that Patient ID #1 was placed on comfort measures as requested by his/her family and later expired at 1:02 PM on 9/7/2024. During a surveyor interview with the evening Supervising Nurse (SRN) Employee F, on 9/12/2024 at 11:30 AM she revealed that after she received her evening supervisor report she later went up to the floor to follow up with Employee C. She then stated that she saw the patient and identified that the patient had a history of constipation and “was not in distress.” Employee F stated she had received a call from Employee C regarding the transfer of Patient ID #1 to the hospital for further evaluation. She then asked Employee C for the patient’s vital signs, then informed her “How can we send someone out that is not in distress.” She stated she thought the situation could wait until morning because the patient was only constipated. Employee F was then asked if she was aware that Patient ID #1 had vomited, to which she replied, “I was not aware of this,” despite her having access to the shift-to-shift report which indicated the patient had vomited x2 unwitnessed on the day shift. During a surveyor interview on 9/16/2024 at 10:48 AM with Institutional Attendant (IAP), Employee G, she stated that on 9/6/2024, she worked second shift and was assigned to a patient on the unit who required one-on-one supervision. She revealed that upon returning to the unit from her break, she was again assigned to the patient who required one-on-one supervision between 8:00 PM and 11:15 PM and was sitting across from Patient ID #1’s room. During this time, Employee G indicated that Patient ID #1 asked to use the bathroom, and she unlocked the door for him/her. She stated that Patient ID #1 was in the bathroom for a while before returning to his/her room. She explained that Patient ID #1 later asked to use the bathroom again, but this time, she observed Patient ID #1 lying on the bathroom floor and another IAP, Employee H, who found him/her said, “Someone needs to call 911.” Employee G states she observed the nurse in the bathroom attempting to give Patient ID #1 a drink, which she/he refused. She indicated that Patient ID #1 then got up from the bathroom floor and laid down in the hallway and the nurse told him/her to return to his/her room, which she/he did. Employee G revealed that she saw Patient ID #1 sitting on his/her bed later in the evening with his/her back against the wall, saying, “Help me, I can’t breathe.” She stated that she had previously reported the patient’s discomfort and his/her “big hard abdomen” to the Nurse Employee C, earlier in the evening, The nurse stated to Employee G, she was aware, and informed Employee G that the patient was constipated. During a surveyor interview on 9/16/2024 at 11:52 AM with Employee H, IAP, she revealed that sometime after 9:00 PM on 9/6/2024, she was conducting safety checks on the unit and Patient ID #1 requested to use the bathroom again. Employee H revealed she checked on Patient ID #1 numerous times as she/he was in the bathroom for a while and asked him/her if she/he was okay and if she/he was breathing, to which the patient replied that she/he was, but stated, “I still don’t feel good,” and eventually returned to his/her room. Employee H indicated the patient requested to use the bathroom again and she saw him/her vomit “a little bit” while sitting in the hallway waiting for the bathroom door to be unlocked and then vomited “brown liquid” when she observed him/her lying on his/her side on the bathroom floor. She stated that she told the patient, “why don’t you sit on the toilet” but the patient told her “I can’t do it” and described his/her face as “bad.” Employee H stated she called the Nurse, Employee C, and told her to call 911, because the patient was “not looking good,” and described his/her face as “very pale.” She stated that the nurse told her she knew and that she told the doctor already. Employee H stated she did not know what else to do, she must listen to the nurse. During a surveyor interview on 9/16/2024 at 12:04 PM with Nurse, Employee E, she stated that on 9/6/2024 she started her shift at 11:15 PM and received report from Employee C. When asked what she was told about Patient ID #1 during report, she stated that Employee C told her that the patient had a problem with constipation, and she told her she administered all of the orders provided to her by the doctor. When asked if she was told if the patient vomited, she stated, “I don’t think that there was vomiting on second shift.” She stated that after receiving report, she gave the IAPs report, and checked on the patient through the door, and saw that Patient ID #1 “was sleeping.” She revealed that around 12:55 AM on 9/7/2024, she heard a cry and when she exited the nurses’ station, she saw Patient ID #1 in the hallway “rolling over” and moving and could not obtain an oxygen level because of this and noticed at this time that the patient’s abdomen was “visibly distended.” She indicated that other staff brought the patient to his/her room where she/he later “passed out” after vomiting. During an interview on 9/12/2024 at 12:15 PM with on-call Psychiatrist, Employee D, she stated she was the on-call Physician and had not received any information on the patient during the Physician handoff report. She revealed she was called three times by the Nurse, Employee C, and at 9:54 PM she received a call from Staff C stating the patient was in discomfort, still had not had a bowel movement and was only taking sips of fluids. Employee D stated that she and Employee C discussed sending the patient out to the Emergency Room for further evaluation and a “verbal agreement was made to send the patient out”. The on-call Psychiatrist then stated that Employee C was asking her questions regarding the process for sending the patient out and she stated that she told Employee C to contact the SRN for the current procedure. During an additional surveyor interview on 9/16/2024 at 12:23 PM with the on-call Psychiatrist, Employee D, she stated that she was unaware that the patient vomited during the day and the evening and stated this would have raised her suspicion for a bowel obstruction. Additionally, she indicated that she was unaware that the patient’s abdomen was “hard and big” or that the patient was pale. Employee D then stated that if these symptoms would have been reported to her, she would have insisted on sending the patient to the hospital. During a surveyor interview on 9/12/2024 at 3:07 PM with Nurse, Employee C, she stated she received in report that the patient was constipated and was told the patient had unwitnessed vomiting. She revealed that the patient refused his/her Miralax and noticed that the patient went to the bathroom multiple times. She indicated that after additional medications such as lactulose and a fleet enema, the patient did not move his/her bowels despite having the urge to go to the bathroom. She indicated that the patient continuously yelled at her that she/he felt full. Employee C revealed that she called Employee D for the third time and stated, “ I think we need to send [him/her] out, there is nothing more we can give [her/him]”, to which Employee D said, “we will send [him/her] out”. Employee C indicated that she then called the SRN, Employee F, who asked for the patient’s vital signs and said, “We cannot send the patient out if [she/he] is not in distress.” Employee C was then asked by the surveyor how do you evaluate if someone is in distress? to which she responded, look at their skin color and see if they are having trouble breathing. Employee C stated she called Employee D back to let her know what the SRN said and that the transfer was cancelled based on the SRN’s recommendation. During an additional surveyor interview on 9/16/2024 at 2:35 PM with Employee C, she revealed that SRN, Employee F, did not assess the patient before making the decision to halt the transfer the patient to the hospital because he was “not in distress”. When asked if she was requested by Employee H to call 911 for Patient ID #1 between approximately 9:00 PM to 10:00PM, she replied that she was notified by Employee H and she was told that the patient just vomited. She acknowledged that she saw vomit on the floor, which she described as 15-20 milliliters of an orange saliva type mixture and revealed that she did not mention this to the oncoming Nurse, Employee E, that the patient had an episode of vomiting. Employee C then stated that when her shift ended Patient ID # 1’s abdomen was “slightly distended” and acknowledged that she knew that he/she was uncomfortable.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 32374 Based on review of hospital policies, review of facility documents, and staff interviews, it was determined that the hospital failed to provide a safe environment (A 0144) and have mechanisms/methods in place that ensure patients are protected from of all forms of abuse, neglect, or harassment as evidenced by the failure to remove a staff member following an allegation of sexual abuse to multiple patients and failing to develop adequate policies to address the protection of patients (A 0145). This failure resulted in an Immediate Jeopardy, posing the potential for serious risk of harm to all patients. Findings are as follows: The hospital administration received an anonymous letter on 7/9/2024 alleging a staff member at the Zambarano Unit of Eleanor Slater Hospital engaged in sexual exploitation of hospital patients. This letter identified a specific staff member by name as the alleged perpetrator. The allegation was also reported to the State Agency (SA). Upon the SA investigation, which began onsite at the hospital on the morning of 7/11/2024, it was identified that the hospital had not informed, interviewed or removed the alleged staff member from performing patient care for which she was still providing on 7/10/2024 and 7/11/2024. Additionally, they had not started interviews with hospital staff or patients. On 7/11/2024 a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR 482.13 A-0115 Condition of Participation: Patient Rights. -The hospital failed to provide a safe environment for vulnerable patients (A-0144). -The hospital failed to protect patients by removal of the alleged perpetrator who was still providing direct patient care for 2 days following notification of the allegation, as well as the failure to begin an immediate investigation once the hospital was aware of the alleged incident on 7/9/2024 (A-0145). On 7/16/2024 an audit was completed by the state surveyor and the Immediate Plan of Correction was verified as fully implemented by verifying policy changes, observations, review of education provided, and interviews with the staff who received the education. As of 7/16/2024 the IJ was removed. 45769”

“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: 45769 Based on review of hospital policies, and staff interviews, it was determined that the hospital failed to provide a safe environment and have mechanisms/methods in place that ensure patients are protected from of all forms of abuse, neglect, or harassment as evidenced by the failure to remove a staff member following an allegation of sexual abuse to multiple patients. Findings are as follows: A facility reported allegation of abuse was submitted to the Rhode Island Department of Health on 7/9/2024, stating the Chief Executive Officer (CEO) of the hospital received an anonymous letter on 7/9/2024 alleging a staff member at the Zambarano Unit of Eleanor Slater Hospital engaged in sexual exploitation of hospital patients by taking pictures of patient’s genitals with their cell phone over the last eight years. This letter identified Staff A, Nursing Assistant, by name as the alleged perpetrator. Findings are as follows: The hospital’s policy entitled, “Abuse and Neglect-Guidelines for Screening and Intervention,” which was last approved on 3/2022 states in part, “II. POLICY: ... 2. All staff at the ESH are responsible to report actual or suspected cases of abuse and/or neglect. The hospital is responsible to evaluate all allegations, observations and suspected cases of neglect, exploitation, and abuse. 3. Staff suspecting abuse or neglect must report suspicions to his/her supervisor. The supervisor is responsible for initiating appropriate actions including notifying his/her supervisor and administration. 4. The Administrator of Risk Management is responsible to notify applicable licensing bodies and authorities within 24 hours...” The hospital’s “Patient Rights and Responsibilities” policy, last approved on 3/2022, states, in part, IV: Policy Statement Pertaining to Patients’ Rights 1. The patient shall be treated with dignity and respect, [and] afforded considerate and respectful care ... 31. The patient has the right to be free from neglect, exploitation, verbal, mental, physical, and sexual abuse.” During an interview on 7/11/2024 at approximately 10:30 AM with the Human Resource Manager, she stated that she was made aware of the allegation on 7/10/2024 and was at the facility to begin the investigation on 7/11/2024. She acknowledged that the employee had not been placed on leave, nor had they been removed from the patient care areas. The Human Resource Manager stated that it is not the hospital’s current practice to place the staff out on a leave, unless the allegation is of “a serious nature”. She was then asked if she considered this allegation to be serious and she responded that “she did, however there were no specifics regarding when, where and which patients were photographed.” During an interview on 7/11/2024 with the Chief Nursing Officer (CNO), at approximately 10:45 AM, she confirmed that the accused staff member worked on the day shift 7/10/2024 and was currently working today (7/11/2024) providing patient care. During interviews on 7/11/2024 at 10:50 AM, with the Risk Manager, CNO, and the Human Resource Manager, they reported that the accused employee was not aware of the alleged allegation and no interviews had been conducted with the accused staff member, current hospital staff or patients regarding the alleged allegation.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 32374 45769 Based on policy review, record review, and staff interviews it has been determined the hospital failed to protect patients by failure to remove a Certified Nurse assistant (C.N.A.) who was alleged to engage in sexual exploitation of patients, and immediately investigate an allegation of sexual abuse. Additionally, the hospital’s policy failed to identify effective components necessary to protect patients from abuse, neglect, and mistreatment. Findings are as follows: A facility reported allegation of abuse was submitted to the Rhode Island Department of Health on July 9, 2024, alleging a staff member at the Zambarano Unit of Eleanor Slater Hospital engaged in sexual exploitation of hospital patients by taking pictures of patient’s genitals. Following the hospital becoming aware of the alleged abuse on 7/9/2024, the hospital failed to immediately notify the alleged staff member and remove them from patient care. The hospital also failed to begin a timely investigation which was not started until after the state surveyor arrived onsite on 7/11/2024. Review of the hospital’s policy entitled, “Abuse and Neglect-Guidelines for Screening and Intervention,” which was last approved on 3/2022 states in part, “II. POLICY: ... 2. All staff at the ESH are responsible to report actual or suspected cases of abuse and/or neglect. The hospital is responsible to evaluate all allegations, observations and suspected cases of neglect, exploitation, and abuse. Further review of the current policy entitled, “Abuse and Neglect-Guidelines for Screening and Intervention,” dated 3/2022, identifies no mechanism to protect the patients from abuse, neglect or mistreatment following an allegation. During an interview on 7/11/2024 at approximately 10:30 AM with the Human Resources Manager, she acknowledged that the employee had not been placed on leave, nor had they been removed from the patient care areas. She stated that it is not the hospital’s current practice to place the staff out on a leave, unless the allegation is of “a serious nature”. She was then asked if she considered this allegation to be serious and she responded that “she did, however there were no specifics regarding when, where and which patients were photographed.” During an interview on 7/11/2024 with the Chief Nursing Officer (CNO), at approximately 10:45 AM, she confirmed that the accused staff member worked on the day shift 7/10/2024 and was currently working today (7/11/2024) providing patient care. During interviews on 7/11/2024 at 10:50 AM with the Risk Manager, CNO, and Human Resource Manager, they reported that the accused employee was not aware of the alleged allegation and no interviews had been conducted with the accused staff member, current hospital staff or patients regarding the alleged allegation.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 43881 Based on record review, staff, and patient interviews, it has been determined that the hospital failed to ensure patients are free from verbal abuse and treated with respect. Additionally, hospital employees failed to report allegations of abuse right away according to the hospital’s abuse reporting practices, for 1 of 4 sample patients reviewed (Patient ID #1). Findings are as follows: On 5/14/2024, the Rhode Island Department of Health received a report from the hospital which alleged that on 5/13/2024 at 7:00 PM, Employee A was speaking “aggressively/disrespectfully” to Patient ID #1. The report indicates that according to the witness’ statement, Employee A was yelling and swearing at the patient and is quoted as stating the following: “I don’t give a f*** what you want to do, and you can do everything for your damn self, you don’t need my help as much as you say you do.” According to Title 23 Health and Safety Chapter 17.8 Abuse in Healthcare Facilities R.I. Gen. Laws § 23-17.8-1, “Abuse” is defined as: “...(v) Intentionally engaging in a pattern of harassing conduct which causes or is likely to cause emotional or psychological harm to the patient or resident, including but not limited to, ridiculing or demeaning a patient or resident, making derogatory remarks to a patient or resident or cursing directed towards a patient or resident, or threatening to inflict physical or emotional harm on a patient or resident.” During a surveyor interview on 6/5/2024 at 11:15 AM with Patient ID #1 in the presence of the Nurse Manager, she/he stated that Employee A was yelling “derogatory things” at him/her the evening of 5/13/2024. When asked to describe what she/he meant by this, she/he indicated that Employee A often yells at him/her to “stay still” or “don’t keep scooting down” and when Employee A is placing a urine collection device on him/her, Employee A says she has to “push your fat over.” The patient stated that Employee A often tells him/her that if she/he does not stay still, “they’re going to take it away,” referring to the purewick urine collection device. The patient indicated that on the evening of 5/13/2024, she had asked Employee A to hold his/her left arm but Employee A “let it drop.” The patient stated that Employee A did use the “f-word” when speaking to him/her the evening of 5/13/2024 and stated she/he felt “terrible” when Employee A used the “f-word” in front of him/her. The patient stated, “It hurts my feelings” when Employee A tells him/her that she will push his/her fat over. The patient revealed that Employee A has been treating him/her this way “for years.” During an interview conducted by the hospital with Patient ID #1 on 5/14/2024 at 10:38 AM, the patient indicated that on 5/13/2024, she/he asked Employee A for help as she/he was trying to undress but Employee A told him/her “you can do it yourself, I can only assist you.” The interview states that the patient reported she/he is sometimes wet from the purewick urine collection device and will ask for help, but Employee A complains that the patient plays with the device and the patient “will lose it if she has to keep changing it.” The patient stated during this interview that Employee A will tell him/her “I have to push your fat over” and that Employee A sometimes “swears at [him/her] and can be loud which makes [him/her] uncomfortable.” Further review revealed the patient stated Employee A, “ ...talks down to [him/her] ...” During a surveyor interview on 6/5/2024 at 10:29 AM with Employee B, Nursing Assistant, she indicated that on 5/13/2024 during the evening shift, she heard yelling from Patient ID #1’s room and she ran fast to see what was going on. Employee B stated she walked into the patient’s room and observed Employee A yelling at the patient, “I don’t give a [f***] about you wanting to go to bed, it’s up to me.” Employee B indicated that she then asked, “what’s going on?” and Employee A said that the patient, “wants to go to bed.” Employee B indicated she left the room and encountered Employee C, Nursing Assistant, in the hallway who asked her, “is she always like this?” referring to Employee A. Employee B indicated that she then spoke to the nurse on duty, Employee D, about the situation and reported it on the following day, 5/14/2024, to Employee E, who was the nurse on duty. During an interview conducted by the hospital with Employee B on 5/15/2024 at 10:45 AM, Employee B revealed that Employee A yelled, “You can do all this [f******] [s***] yourself.” Additionally, according to the interview, when Employee B asked Employee A and Patient ID #1 what was going on, Employee A replied, “Nothing. [She/He] can do all this on [his/her] own. [She/He]’s being lazy.” Further review of this interview states in part that Employee B reported the incident to Employee D who told her, “this happens all the time.” During an interview conducted by the hospital with Employee C, Nursing Assistant, Employee C revealed she was in the room next to Patient ID #1’s room and heard the patient yell, “I’m not finished” to which Employee A replied, “that sounds like a personal problem.” Employee C stated she heard Employee A say, “I don’t give a [f***] if you want to go to bed.” Employee C stated during this interview that she also saw Employee A enter another patient’s room and say, “who the [f***] left you like this.” During an interview conducted by the hospital with Employee D on 5/16/2024 at 10:30 AM, Employee D revealed that when Employee A answers call lights she “will say ‘what’ or ‘What now’.” Further review revealed that Employee D stated nothing had been reported to her on the evening of 5/13/2024. During an interview conducted by the hospital with Employee E on 5/16/2024 at 3:25 PM, he described Employee A as “ ...abrupt, rough around the edges ...” and stated, “ ...there is room for coaching [Employee A] on how she speaks to patients.” During an interview conducted by the hospital with Employee F, Nursing Assistant, on 5/16/2024 at 3:15 PM, she revealed she heard “a commotion” in Patient ID #1’s room but thought the patient and Employee A were joking and heard Employee A say, “you can do it faster.” Record review of Patient ID #1’s “Medical Nursing Flowsheet” dated 5/13/2024 revealed a section titled, “Signs of Abuse and Neglect” for which employees are to document “Observed/Reported or None.” Review of the 3:00 PM to 11:00 PM shift documentation on this flowsheet revealed this section was not updated to reflect the allegation of abuse as witnessed and heard by the employees on duty the evening of 5/13/2024. Review of the hospital’s Investigative Summary stated that it was determined Employee A engaged in “inappropriate/unprofessional conduct” while interacting with the patient which violated the hospital’s “Standards of Conduct” since she used “vulgar language.” The summary further states, “all staff are always expected to perform the duties of their positions in an appropriate, professional, and respectful manner.” During a surveyor interview on 6/5/2023 at 9:30 AM with the Nurse Manager in the presence of the Interim Chief Nursing Officer and the Risk Manager, the Nurse Manager indicated she was made aware of the allegation the next day, 5/14/2024, at 9:25 AM following an incident report submitted that morning by Employee E. She indicated that concerns related to abuse are to be reported right away but was unable to explain whether Employee B reported the incident right away after she witnessed it, since Employee D indicated, nothing was reported to her. Additionally, the Nurse Manager stated she would be re-educating Employee B about the hospital’s reporting practices.”