HospitalInspections.org

Based on record review and staff interviews, it was determined that the hospital failed to ensure that staff who had knowledge of or reasonable cause to believe that a patient had been abused, notified Risk Management immediately in accordance with hospital policy for 1 of 3 patients reviewed for abuse, (Patient ID #1).

Findings are as follows:

The hospital's policy titled, "Mandatory Reporting of Patient Abuse & Patient-To-Patient Abuse" last revised in July of 2022 states in part,

" ...Abuse ...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 ...cursing directed towards a patient or resident ...
Procedure ...

...Any healthcare worker who has knowledge of or reasonable cause to believe that a patient has been abused ...shall notify the Risk Management Department immediately ..."

On 4/28/2025, the hospital submitted a report to the Rhode Island Department of Health in which a nurse alleged that she heard another nurse, Employee A, yelling at his patient telling the patient to "f***ing stop" multiple times while giving the patient a bath and changing the linen.

During a surveyor interview on 5/1/2025 at 8:46 AM with Employee B, Registered Nurse (RN), she stated that on 4/25/2025 at approximately 4:00 AM, she was inside a patient's room when she heard "yelling" on the unit. She revealed that she then came out of her patient's room, onto the hallway and heard Employee A, who was inside Patient's ID #1's room behind a closed curtain, yelling, "stop it! f***ing stop!", and "stop it right now!" She stated that she started to walk toward the yelling and Employee A suddenly opened the curtain and stepped out of the Patient ID #1's room. She stated that she asked Employee A if he needed help, but he said no.

Employee B revealed that Employee A and the patient were the only ones inside the room and the patient was not the one yelling because the patient was "nonverbal" and dependent on staff for assistance. Employee B revealed that she has cared for the patient many times before and stated that the patient "can latch onto you, but it is only a simple hold and is never aggressive."

Record review of the nursing schedule for Employee A, revealed that he continued to work on 4/26/2025 and on 4/27/2025 alongside Employee C, RN.

During a surveyor interview on 5/1/2025 at 11:03 AM with Employee C, RN, he confirmed that he worked with Employee A during the overnight shift on 4/26/2025 and on 4/27/2025. Employee C stated that he never saw Employee A provide direct patient care but stated that Employee A was "short with patients over the weekend." When asked to elaborate, Employee C stated that Employee A was "getting frustrated" and he heard him "speaking loudly to the patients." When asked to describe Employee A's tone when speaking to the patients, Employee C stated, "frustrated, seemed angry at times," and was speaking to the patients in an "angry" tone since the patients had been either pulling and removing their medical devices.

During a surveyor interview on 5/1/2025 at 9:59 AM with the Risk Manager, she acknowledged that Employee B did not report Employee A's behavior to the Risk Management Department immediately in accordance with hospital policy until submitting a report on 4/28/2025, three days after the incident took place.

Based on record review and staff interviews, it was determined that the hospital failed to ensure that a licensed nurse adhered to the standards of nursing practice related to the removal of a medication from the Omnicell dispensing system under one patient's name for personal use, using another individual's identity, (Patient ID #4).

Findings are as follows:

On 5/6/2025, the Rhode Island Department of Health received an anonymous complaint in which numerous statements were made against Employee D, the Psychiatry Department Manager, one of which alleged that on 5/2/2025, Employee D placed a physician's order for Ibuprofen 800 milligrams (mg) on Patient ID #4's medical record without a doctor's order and under a false provider name. The allegation further stated that Employee D took the medication from the Omnicell and then "returned it."

During a surveyor interview on 5/8/2025 at 9:46 AM with Employee E, Registered Nurse (RN), she explained that on 5/2/2025, Patient ID #4, was complaining of right-sided hip pain and so she reviewed the patient's medications to see what she could administer. She stated that she saw an order for Ibuprofen to be administered "now" and so she "acknowledged it" in the medical record. She then went to the Omnicell to retrieve the Ibuprofen but was unable to get it as it was no longer "populating" in the system. She then notified the hospital pharmacist who told her at the time that the order did not look like a physician's order as it was removed as an "override" from the Omnicell. Employee E revealed that she spoke to Employee G, RN, about the Ibuprofen and he notified the Physician, Employee H, who prescribed Tramadol and a lidocaine patch for the patient's pain instead.

Record review of the Omnicell transaction report from 4/7/2025 through 5/7/2025 revealed an entry on 5/2/2025 which indicated that Employee D removed an Ibuprofen (Motrin) 800 mg tablet at 3:16 PM under Patient ID #4's name. The report then indicated that at 3:17 PM, the Ibuprofen 800 mg tablet was returned to the Omnicell.

Record review of the "Order Audit Trail" report for the Ibuprofen tablet confirmed that the tablet was removed from the Omnicell as an override by "Employee F" at 3:16 PM on 5/2/2025, not Employee D.

During a surveyor interview on 5/7/2025 at 11:51 AM with the Risk Manager, she revealed that she received a report about Employee D retrieving Ibuprofen from the Omnicell and on the morning of 5/7/2025, she asked Employee D about it. The Risk Manager revealed that Employee D acknowledged that she removed the Ibuprofen from the Omnicell under Patient's ID #4's name to give it to a Certified Nursing Assistant on duty and that "it was a bad decision."

During a surveyor interview on 5/7/2025 at 1:11 PM with Employee D, the Psychiatry Department Manager, she was asked about the Ibuprofen she removed from the Omnicell on 5/2/2025 under Patient ID #4, to which she stated that it was "a failed override attempt" and indicated that it was "accidental", and the patient did not get the Ibuprofen. She stated that she spoke to Pharmacy about it as it was "done in error" under the patient's name. When asked why she removed the Ibuprofen from the Omnicell under the patient's name, she stated that it was for "nonbusiness reasons." When asked what the purpose was for removing the Ibuprofen from the Omnicell if not for business reasons she stated, "possibly for myself, not for a patient."

During an additional interview with the Risk Manager on 5/8/2025, she acknowledged that Employee D should not have removed the Ibuprofen from the Omnicell under Patient ID #4's name for herself or any of the staff as this is not the standard of practice.