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Based on record review, policy review, and staff interviews, it was determined that the hospital failed to meet §482.55 Condition of Participation: Emergency Services after the following was identified:

The Emergency Department staff failed to follow the hospital's triage protocol relative to verifying patients' allergies. This failure resulted in an Immediate Jeopardy, that placed patients at risk of serious harm, serious impairment or death. (Refer to 1104)

Findings are as follows:

A Centers for Medicare/Medicaid Service (CMS) authorized Federal substantial allegation survey was completed from 9/9/2025 through 9/11/2025 at Kent County Memorial Hospital to determine compliance with §482.55 Condition of Participation: Emergency Services.

It was determined that the hospital was not in substantial compliance with the requirements of §482.55 Condition of Participation: Emergency Services after a patient who was evaluated in the emergency department (ED) was administered an antibiotic which they had a confirmed allergy to. Staff failed to follow established policies and procedures of the ED, as the staff neglected to thoroughly review all of the documents that were provided with a patient when they were transferred to the ED from the transferring facility, prior to administering medications.

As a result of the identified non-compliance, Patient ID #1 was administered a medication that he/she was allergic to.

The hospital was informed of the Immediate Jeopardy and was provided with the Immediate Jeopardy template on 9/10/2025 at approximately 12:00 PM, after it was identified.

On 9/10/2025, the hospital submitted an 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:

- The development of a Nursing Practice Alert that would direct all ED nurses to review all documentation accompanying a patient who was transferred into the ED from an outside facility. This Practice Alert will be issued to all Nurses via email and will be posted at all ED nursing stations.

- A formal protocol was to be immediately drafted to provide guidance to registered nurses regarding the management of information appearing on documentation accompanying patients who are transferred to the hospital from an outside facility.

- All Emergency Department Nurses on all shifts would receive in-person, onsite education, prior to the start of their shift, until all ED nurses have received the training.

The following materials were reviewed as part of the training:

a. Kent Hospital ED Protocol: Review of External Documentation from External Facilities

b. Practice Alert: Allergy Verification Required: Every Patient, Every Time

All Emergency Department Nurses on all shifts were required to conduct a "Read and Sign" of the above training.

The ED Triage Competency Check List will now include "Review the Continuity of Care Form or any other Discharge/Transfer Form" that may accompany a patient from an outside transferring facility and confirm and reconcile all allergies against the existing allergies listed in the electronic medical record.

The following hospital policies were revised:

KH-NUR-610 - Medication Reconciliation Policy would now include COC and Discharge/Transfer forms to the list of "appropriate and reliable sources" for medication reconciliation.

KH-NUR-607 - Medication Administration Policy (Section IV(c)(4) Points of Emphasis would now include COC and Discharge Forms from outside facilities in the list of sources where allergies are confirmed prior to administering a medication.

KH-ED-036 - Assessment/Reassessment of patients in the Emergency Room policy (Section IV (f)(2) Procedure) would include specific guidance to review all documentation that accompanies a patient from an outside transferring facility for allergies and other pertinent information.

On 9/11/2025 at 1:30 PM the State Survey Agency confirmed the above plan was implemented through observation of the triage process, record review, and interviews with multiple nurses in the ED confirming that staff had received, reviewed, and were implementing the above training and received the education.

Based on record review, policy review, and staff interviews, it has been determined that the hospital failed to ensure that the emergency department (ED) staff followed the hospital's triage process related to verifying a patient's allergies for 1 of 5 patients reviewed, Patient ID #1. This failure resulted in a patient receiving an antibiotic intravenously (IV) that they had a known allergy to.

Findings are as follows:

On 9/8/2025, The Rhode Island Department of Health received a complaint in which the family of Patient ID #1 alleged that when they arrived at the ED the patient was receiving Vancomycin (an antibiotic) via IV, a medication that the patient had a known allergy to.

Review of the hospital's policy titled, "Assessment/Reassessment of Patients in the Emergency Department", effective 2/12/2025 states in part: "...The ED RN's [registered nurse's] initial assessment data will include. But is not limited to... (2) Chief complaint. Pain severity, allergies ..."

Review of Patient ID #1's ED record revealed the patient was transferred via Emergency Medical Services (EMS) from a skilled nursing facility on 9/4/25, with lethargy and a low grade fever.

The patient's spouse presented to the ED and observed intravenous Vancomycin medication being infused into the patient. S/he alerted the staff of the patient's allergy, and asked them to discontinue it.

Review of the "Transfer and Discharge Report ", which accompanied the patient when they arrived to the ED from the skilled nursing facility, revealed that the patient was allergic to Vancomycin.

Review of the Rhode Island EMS Patient Care Report dated 9/4/2025, under "Medication Allergies" identified that the patient was allergic to Vancomycin.

Review of the initial patient assessment completed by Nurse Staff A, upon arrival in the ED, revealed the following was checked off as completed:
...allergies were "reviewed and documented."

Review of the ED medication orders for Patient ID #1 revealed that Vancomycin 925 mg IV had been ordered by ED Attending Physician, Staff B.

During a surveyor interview on 9/10/2025 at 11:51 AM with Staff A, she stated that she had received a verbal report from EMS for Patient ID #1 when s/he arrived presented to the ED and began her assessment of the patient. She confirmed that she had also received transfer paperwork from the skilled nursing facility, which she glanced over. She stated the patient's family was not present when the patient initially arrived, and the patient was nonverbal. Staff A stated she reviewed the patient's allergies in the hospital's electronic record system.

Additionally, Staff A revealed that once Patient ID #1's spouse arrived in the ED on 9/4/2025, and saw that the patient was receiving IV Vancomycin, s/he informed her that the patient was allergic to Vancomycin. The infusion was then stopped and she notified Staff B.

During a surveyor interview with, Staff B, on 9/10/2025 at 12:10 PM, she stated that she had reviewed the patient's allergies that were recorded in the hospital's electronic medical record. Staff B confirmed that she was unaware of the patient's allergy to Vancomycin.

During an interview with the Director of Risk Management, Staff C, on September 9, 2025, at 3:00 PM, she acknowledged that the skilled nursing facility's "Transfer and Discharge Form" and The Rhode Island Emergency Medical Services "Run Sheet" listed that the patient had an allergy to Vancomycin. Additionally, she acknowledged that the patient's hospital electronic was not updated to include his/her allergy to Vancomycin and should have been.