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Based on record review and staff interview, the hospital failed to ensure that 1 of 4 patients reviewed (Patient ID#1) was able to participate in the implementation of his/her plan of care when a physician (Employee A) failed to respond to nursing staff's repeated requests for pain management during labor. This failure resulted in the patient experiencing unmanaged labor pain, contrary to his/her expressed pain management plan.

Findings are as follows:

A complaint submitted to the Rhode Island Department of Health in September of 2025 alleged in part that during an induction of labor at the hospital, Patient ID #1 was "forced" to "endure unnecessary pain, suffering, and trauma." The complaint further alleged that an epidural (anesthesia injection) was requested "again" for pain "when the pain became extremely tortuous," but the patient was informed that there were no rooms available in the Labor and Delivery Unit. The complaint alleged that the nurse said she would page the doctor for the approval of morphine (medication used to treat pain), but an hour went by without response from the doctor. Patient ID #1 alleged that she/he experienced "uncontrollable body spasms without nothing to manage the pain."

Record review revealed that Patient ID#1 was admitted to the hospital in July of 2025 for an induction of labor.

The record revealed a plan of care for the patient that stated the patient was to receive intravenous pain medications on an as needed basis while on the Antenatal Care Unit (ACU) and "per patient request," the patient was to receive an epidural (anesthesia injection) and nitrous oxide ("laughing gas") while on the Labor and Delivery Unit.

At 10:32 PM on 7/26/2025, the patient rated his/her pain as 6 out of 10 and was administered morphine intravenously.

At 12:03 AM on 7/27/2025, the patient's contractions were described as "strong."

At 12:48 AM, the patient's nurse (Employee B) paged the physician (Employee A) requesting assessment and "maybe" more intravenous pain medication. Employee A then assessed the patient at 1:10 AM, during which the patient requested an epidural. However, the epidural was not administered.

At 1:30 AM, the patient rated his/her pain as 8 out of 10 and it was described as "intermittent," "gradual," and "cramping." Another provider (Employee C) then assessed the patient at 1:47 AM and indicated that during the exam, pain management options were reviewed with the patient, however, no specific orders or plans were documented.

At 1:47 AM, Employee B paged Employee A stating that the patient "would like morphine ordered." However, the record failed to reveal evidence that a morphine order was placed or administered as outlined in the patient's initial plan of care for as needed intravenous pain medication while in the ACU.

At 1:59 AM the patient contractions continued and were described as "strong."

At 2:35 AM, a nursing progress note indicated that the patient's significant other reported that the patient was "convulsing" with contractions. Employee B indicated in the note that she explained these "labor shakes" and again contacted the Charge Nurse on the Labor and Delivery Unit to report that the patient was "extremely uncomfortable."

At 2:39 AM, the nurse indicated in the record that she was "unable to get the nitrous to work" and spoke to the Charge Nurse in the Labor and Delivery Unit again to "get pt [patient] down ASAP [as soon as possible]."

At 2:41 AM, Employee B paged Employee A again, stating that the patient was "super uncomfortable" and to "please put in morphine order." Employee B further indicated that the nitrous oxide tank was not working because it was broken and to "please" order morphine because the patient was "in agony."

At 3:04 AM, the patient arrived on the Labor and Delivery Unit "very uncomfortable" requesting an epidural.

The patient then delivered at 3:10 AM without receiving any pain medication despite his/her requested preferences or Employee B's efforts to obtain an order for morphine. Additionally, the record failed to reveal evidence that Employee A responded to Employee B's requests or ordered morphine or alternative analgesia prior to delivery.

During a surveyor interview with the Clinical Effectiveness Manager on 7/26/2025, she was unable to provide evidence that Employee A responded to the pain medication requests sent by Employee B or that the patient's pain was addressed in accordance with his/her plan of care and preferences.