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Based on record review and staff interview, it was determined that the hospital failed to enforce its rules and regulations established for the medical staff relative to the documentation of progress notes in the medical record for 1 of 2 patients reviewed (Patient ID #1). Additionally, the hospital failed to ensure that a Third Year Resident who is part of the hospital's code team was up to date with their Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certifications in accordance with hospital policy (Employee B).

Findings are as follows:

The hospital's "Medical Staff Rules and Regulations" state in part,

" ...V. Medical Records
...3. Progress Notes: Pertinent progress notes shall be recorded at the time of evaluation, sufficient to permit continuity of care and transferability. Whenever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatments ..."

Review of Patient ID #1's Medical Record, revealed a Significant Event Note dated 1/4/2025 written by Employee A, Registered Nurse, stating that while rounding she heard sounds coming from the patient's room and went in to check on the patient. The note revealed Patient ID #1 then told the nurse that she/he accidentally spilled hot coffee on themselves. The Registered Nurse then applied cold washcloths to the skin and notified the On-Call Resident. The note then revealed that the intern came to assess the patient and recommended petroleum jelly to the skin.

Patient ID # 1's medical record revealed no evidence of any documentation from the physician, regarding their assessment of the the injury or treatment order for the injury on 1/4/2025.

During a surveyor interview on 1/21/2025 at 2:00 PM with Employee B, Third Year Medical Resident and Attending Physician, Employee C, and First Year Intern, Employee D, the patient's medical record was reviewed. Employee B, Third Year Medical Resident, confirmed that she was covering the patient on the day she/he received the burns. She acknowledged that she received a call from the patient's nurse, Employee A, stating that Patient ID #1, spilled hot coffee on themselves and needed to be seen. The resident then stated that she sent the intern to see the patient. She then confirmed that she did not see the patient's injury on 1/4/2025. The Intern, Employee D, was then asked if she was the intern who went up to evaluate the patient on 1/4/2025. She stated that she was not. Employee B then revealed that she had sent Employee E, First Year Resident, to evaluate the patient. Both the Attending and the Third Year Resident could not provide evidence of physician notes documenting that the patient was evaluated on 1/4/2025 despite the patient being seen by the first year resident on 1/4/2025. Employee C was then asked if it is his expectation that an intern or resident should write a note after they see a patient, to which he answered yes and that it was dependent on the situation.

2. Review of the hospital's policy titled "BLS and ACLS for House Officers" states in part:

"Policy ...All house officers will maintain BLS and ACLS certification consistent with Rhode Island Hospital policy in effect during their training period ..."

Record review of the medical staff credentialing files on 1/21/2025 revealed that Employee B, Third Year Resident, has been practicing with an expired BLS and ACLS certification since 6/30/2024.

During an interview with the Chief Resident, Employee F, on 1/21/2025 at 3:30 PM, she confirmed that Employee B has continued to participate in the Hospital's Code Team responses from July 2024 to Present.








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