HospitalInspections.org

Based on record review, and staff interview, the hospital failed to ensure a developmentally disabled patient receives dignified and respectful treatment in an environment which feels safe and supportive related to an Emergency Department (ED) Physician who displayed unprofessional conduct while providing care for 1 of 1 patient reviewed, (Patient ID #1).

Findings are as follows:

On 7/9/2025, a community reported complaint was submitted to the Rhode Island Department of Health alleging that while in the ED at the hospital they witnessed Physician, Staff C, inappropriately speaking to a developmentally disabled patient.

Record review for Patient ID# 1 revealed s/he presented to the ED in July of 2025 for an injury to his/her ankle after eloping from the group home which s/he resides. The patient had no injury noted to his/her ankle and was discharged home. The patient was transported to the group home by ambulance. Upon return, s/he refused to get off the stretcher and became combative with staff. The ambulance immediately returned the patient to the emergency department for evaluation.

Review of the Physician, Staff C's ED documentation revealed that she had assumed care of the patient during the patients return ED visit.

Record review indicated the patient was seen for a behavioral health assessment which identified no behavioral concerns. The patient was cleared for discharge to back to the group home. The patient refused to leave, sat on the floor in the corner of the room refusing to leave the hospital. This resulted in a call for law enforcement to assist. Nursing documentation revealed the patient was displaying disruptive behaviors noted by blocking the doorway. As staff went to close the doorway the patient struck a security officer in the face. The Physician, Staff C, was at the bedside and the patient was medicated and placed in four point restraints.

During a surveyor interview on 7/15/2025 at 1:30 PM, with the complainant, who was present during the altercation, described that law enforcement was called to the hospital on 6/10/25 to assist with the patient's refusal to leave the hospital ED. Upon arrival the patient was sitting on the floor, calmly in the corner of the room, refusing to get up and leave. Physician, Staff C informed the complainant that she called law enforcement to help physically remove the patient from the building. Law enforcement informed her that they were not able to put their hands on the patient. The Physician, Staff C was noticeably frustrated. The patient opened the room door, Charge Nurse, Staff B went over to close the door, and the situation escalated, the patient became physically combative with the staff member and security, the patient was forced onto a stretcher, medicated and placed in four point restraints. Physician, Staff C was observed saying to sedate the patient and said do it "with a really big needle". Physician, Staff C came into the room yelling at Patient ID #1 saying if they were going to act like a two year old they were going to be treated like a two year old. Repeating the instruction "no food or water". The complainants stated that they were disturbed by the way that Physician, Staff C treated the patient.

During a surveyor interview with the ED Director, Staff D, on 7/16/2025 at 12:05 PM, he stated that he had spoken to the Physician, Staff C regarding the alleged incident. Physician, Staff C stated that she was frustrated with the patient and confirmed that her behavior was not appropriate, but did not elaborate further.

During a surveyor interview with Charge Nurse, Staff B on 7/16/2025 at 1:30 PM, he explained that there was a team which included ED staff, security, and the local police department trying to safely discharge the patient without putting hands on the patient. Charge Nurse, Staff B described Physician, Staff C as very frustrated because she wanted the police to remove the patient from the emergency room. He confirmed he did hear the Physician, Staff C say not to give the patient food or water but explained that she was speaking about not offering it as a reward. He referred to the providers behavior as blunt, stating she is from the "urban hospital environment which is not typical here."

Based on record review and staff interview it has been determined the hospital failed to ensure a physician's order is obtained for the application of violent restraints for 1 of 5 patients reviewed, Patient ID #1.

Findings are as follows:

The hospital's policy titled, "Restraints" revised 6/2023 states in part,

" ...Staff members and providers that participate in ordering, applying and removing restraints will have training at orientation ...

A provider order is required for the use of restraint ..."

1. Record review for Patient ID #1 revealed that a 4-point limb restraint was applied to this patient while in the Emergency Department in June of 2025 beginning at 10:07 PM and ending at 12:02 AM.

The Record failed to reveal evidence that a physician's order was obtained for the application of the 4-point limb restraint.

During a surveyor interview with Staff A on 7/15/2025 at 3:30 PM, she acknowledged that the medical record for Patient ID #1 did not contain a physician's order for the 4-point limb restraint that had been applied to Patient ID #1.

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 transferring patients via a mechanical lift for 1 of 1 patient reviewed who slid from the lift pad during a transfer, Patient ID #1.

Findings are as follows:

Review of the hospital Policy titled, "Safe Patient Handling" which states in part:

A. "Definitions:

4. Patient Handling Equipment and Aids: Equipment used to assist in the lift or transfer process. Included in this category are the following:
5. Mechanical Patient Lifting Equipment: equipment used to lift, reposition and move patients.

10. Safe Patient Handling Committee (SPHC): The SPHC is a multidisciplinary team responsible for ensuring that the Hospital has a comprehensive safe patient handling program. The committee is chaired by a nurse manager and will report to the nursing leadership committee and quarterly to the hospital wide performance improvement steering committee."

Review of the hospitals "Safe Patient Handling Procedure" which states in part:
"Reassessment:

B: Daily Safe Patient Handling and Movement Considerations:

3. The plan will use the mechanical lifting devices and other approved patient handling aids for high-risk patient handling and movement task.

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 Patient ID #1 was seated in his/her wheelchair on a lift pad. When preparing the patient for the transfer back to bed, she reports she did not cross the lift straps around the patient's legs as required because the patient asked her not too.

During an interview with the Nurse Educator, Staff D, on 7/22/2025 at approximately 2:30 PM, she stated that pads all have a manufacturer label attached that shows a diagram of how to apply the lift pad. Staff D informed the surveyor that she is the chairman for the safe patient handling committee.

A review of the policy titled "Safe patient Handling",
Under ....states ...the Safe Patient Handling Committee reports to the Performance Improvement Committee monthly ...
..The safe Patient Handling Committee will conduct an annual performance evaluation of the safe patient handling program.
The surveyor requested to review the annual performance evaluation of the safe patient handling program, Staff D stated that the committee had not met in "a while".

A Review of the information provided, reveals the committee met in January 2024, and September 2024. She was unable to produce evidence of data or evaluations that the SPHC is functioning in accordance with the hospitals policy related to quarterly reporting to the hospital performance improvement steering committee.