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

1. Emergency department staff failed to follow established policies and procedures in the emergency department regarding the review and clarification of new prescriptions upon discharge, (Refer to 1104).

2. An emergency department provider prescribed a new medication to a patient with a documented allergy, resulting in the patient experiencing an adverse drug reaction, (Refer to 1104).

These failures resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment or death to all patients.

Findings are as follows:

A Centers for Medicare/Medicaid Service (CMS) authorized Federal substantial allegation survey was completed on 7/3/2025 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 was prescribed a new medication at discharge to which they had a documented allergy. Staff failed to follow established policies and procedures in the emergency department related to reviewing and clarifying new prescriptions with patients upon discharge and ensuring patients' allergies are confirmed prior to prescribing medications.

As a result of the identified non-compliance, Patient ID #1 was prescribed a medication she/he was allergic to upon discharge from the emergency department. The patient then took the medication as prescribed and experienced symptoms including itchy/scratchy throat and tightening of muscles in the throat and shoulders.

The hospital was informed of the Immediate Jeopardy identified on 7/2/2025 and was provided with the Immediate Jeopardy template at approximately 1:50 PM on this date.

On 7/3/2025, 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:

- Developed a Nursing Practice Alert outlining the step-by-step process for discharging a patient in the Emergency Dept. In addition to general discharge steps, this Practice Alert specifically addresses clarification of discharge orders with the provider and review of new prescriptions issued to the patient.

- Immediately, this Practice Alert will be issued to all Nurses via email and AMS intra-hospital texting mechanism.

- Immediately, all Emergency Department Nurses on all shifts will receive onsite education to review:

a. KH-ED-029 Discharge of the ED Patient
b. Practice Alert: Process for Discharge of Emergency Department Patients
c. Discharge documents provided to patients: Patient Visit Summary, Emergency Services - Discharge Instructions

- Immediately, all Emergency Department Nurses on all shifts will be required to conduct a "Read and Sign" of KH-ED-029 Discharge of the ED Patient.

- Immediately, all ordering providers on all shifts in the Kent Hospital Emergency Dept. will receive in-person, onsite education related to decision support allergy alerts and medication prescription management.

- Immediately, when prescribing new medications to an emergency department patient, all ordering providers will be required to document the generic and name brand of the medication in the "Follow Up Care" field in the provider note. This action will cause the generic and name brand of the medication to auto populate into the ED Patient Education document that is used by the discharging RN to review with the patient upon discharge. The patient also receives a copy of this document for reference post-discharge.

- Immediately, the Chief of Emergency Medicine will issue an email with High Importance instructing all prescribing providers to:

a. Carefully review and verify all patient allergies before prescribing or administering medications.
b. Carefully contemplate all decision support allergy alerts that may trigger during the ordering process.
c. Document the generic and name brand of new medications prescribed to the patient during the encounter in the "Follow Up Care" field in their provider note so that this information auto populates into the patient's Discharge Education documentation.

- Kent Hospital utilizes an electronic medical record implemented by Cerner Software. When a patient has a documented allergy, the decision support software fires an allergy alert "pop up." Currently, prescribing providers have multiple override choices when contemplating whether to prescribe a medication to a patient who has a documented allergy. To mitigate confusion and augment the prescribing provider's use of discretion when selecting a reason for override, the Decision Support allergy alert override reasons have been revised to only display three acceptable options:

1. Home med taken w/out reaction
2. Patient being monitored
3. Free Text

On 7/3/2025, the State Survey Agency confirmed during a review of medical records from patients discharged from the emergency department and interviews with nurses and physicians on duty in the emergency department, that staff had received, reviewed, and implemented training related to reviewing and clarifying new prescriptions and confirming patient allergies.
As of 7/3/2025, the Immediate Jeopardy was removed.

Based on record review, surveillance video review, and staff interview, the hospital failed to ensure a patient's right to receive care in a safe setting was upheld when excessive force was used during the application of a restraint, for 1 of 3 patients reviewed, (Patient ID #1).

Findings are as follows:

On 6/13/2025, Patient ID #1 submitted a complaint to the Rhode Island Department of Health alleging that while in the emergency department, she/he was restrained with excessive force and punched in the face resulting in bruising and injury to his/her left wrist and right fourth finger.

Record review revealed the patient presented to the emergency department in June of 2025 via ambulance after making suicidal statements.

Record review of nursing progress notes revealed that Staff I asked the patient to hand over his/her phone, however, the patient indicated that she/he would hand his/her phone over after she/he finished sending a text message. According to Staff G, "after about a minute," Staff I asked the patient to hand over the phone again, to which the patient replied while yelling, she/he was not finished. Staff I then "took the phone" from the patient at which point she/he began to yell derogatory terms at Staff I. Staff G stated that that she and Staff H attempted to deescalate the patient as Staff I walked away with the patient's phone. However, the patient was not receptive, she/he unbuckled himself/herself from the stretcher, "lunged toward [Staff H] to try and push his/her out of the way to get to [Staff I]" who had his/her phone, while telling Staff G and Staff H to "Shut the f*** up." Staff J then intervened and attempted to guide the patient to a hallway chair, however, both the patient and Staff J fell to floor along with Staff I, both of which held the patient down on the floor to prevent the patient from "swinging at staff." Additional personnel and Staff K were then summoned to the scene.

According to Staff G, the patient then began to scream that his/her back was in pain due to his/her recent surgery, however "proceeded to try and kick at staff." Following the arrival of extra personnel and Staff K, the patient began spitting at Staff J, who used his open hand to guide the patient's chin to the side to prevent the patient from spitting on his face. Staff G indicated that Staff K ordered restraints for the patient as she/he continued to "verbally assault staff", "thrash", and "hit staff". When the patient was assisted to a standing position, she/he attempted to "violently kick" staff and was then "guided" into a patient room where his/her limbs were held down by staff for the restraints to be applied. During the application of restraints, the patient was "trying to knee staff", "tried to fight staff" and tried to spit at Staff J, at which point Staff J again "guided" the patient's face away in the same manner as before. Staff G indicated that a spit mask was applied to the patient and the patient was "threatening to hit staff" yelling, "you're breaking my wrists I felt a pop, my arm is broken!", "you guys broke my hands" and "that guy punched me in the face!"

Staff G further stated that Staff K attempted to deescalate the patient and assess him/her but she/he continued to "yell and thrash" and sedating medications were ordered and administered. Staff G indicated that despite their attempts to deescalate patient and medicating him/her, the patient "continued to thrash in bed and yell out" and was observed on camera removing his/her wrist restraints which were reapplied.

Record review of a Musculoskeletal Assessment performed by Staff G on 6/11/2025 at 7:30 PM, revealed the patient had tenderness on their right and left wrists, and edema (swelling) and tenderness on a finger of the right hand.

Record review of Staff K's documentation revealed that staff reported to him that the patient was asked multiple times to stop texting and turn his/her phone over. Staff K indicated that although the patient was "given time to comply", the patient did not, and staff "attempted" to retrieve the phone, and the patient became "highly assaultive and started kicking staff". Upon his arrival, the Staff K indicated that the patient was lying on the floor "attempting to kick staff", "screaming", and "resisting". Staff K stated that he observed staff attempting to stand the patient at which point he observed the patient "violently kick" multiple staff who then "tackled" him/her onto a patient bed where 4-point restraints were applied.

According to Staff K, the patient reported she/he "felt a snap" in his/her left wrist and pain in his/her fourth finger of the right hand.

Record review of a Physical Examination performed by Staff K revealed that the patient had a "deformity" at the tip of the right fourth finger.

Record review of Staff H's documentation revealed Staff H was inside of the nurses' station when she observed the patient typing on his/her phone when she/he was approached by Staff I who was requesting his/her phone. Staff H indicated that the patient began yelling and refused to hand his/her phone over at which point, Staff I attempted to physically remove the phone from the patient's hands. Staff H stated that the patient said she/he was "texting my sister that I'm here" and "give me a moment". Staff H indicated that she observed Staff I "step back in apparent agreement" but "after several seconds" when the patient continued to text, Staff I attempted to remove the phone from the patient's hands again while she/he continued to yell and refuse. Staff H indicated that upon exiting the nurses' station, Staff I had "disengaged" from the patient with his/her phone in his hand. Staff H stated that she then observed the patient unbuckle himself/herself from the stretcher while screaming at Staff I to return his/her phone, she/he jumped off the stretcher, and grabbed at Staff H in an attempt reach Staff I who had retrieved his/her phone. Staff J then intervened and restrained the patient with Staff I while the patient screamed, flailed, kicked, grabbed, and hit Staff J and Staff I.
According to the Staff H, the patient was assisted to stand, struggled, and kicked staff and was assisted to a patient room where restraints were applied, but the patient continued to scream, verbally aggress toward staff and repeatedly yell "shut the f*** up". Staff H stated that throughout the episode, the patient stated that she "had a broken back", "they punched me in the face!", "they punched me in the jaw", "they broke my finger!", "they broke my wrist!", and "they cracked my wrist!"

The record indicated that the patient eventually calmed, restraints were removed, she was medically cleared and then transferred to another hospital for further management.

Record review of the patient's discharge documentation revealed that the patient's associated diagnoses included "finger sprain".

During a review of recorded surveillance video in the presence of Staff E on 7/3/2025 at 12:49 PM, the patient was observed arriving on the unit laying on a stretcher accompanied by ambulance personnel. The patient was observed holding his/her cell phone with both hands, actively engaging with the device as the screen was visibly illuminated. Staff I was observed attempting to retrieve the patient's phone from his/her hands multiple times and is at one point observed holding the patient's left arm attempting to retrieve his/her cell phone from their right hand as she/he waved if away from Staff I. The patient was observed pulling away from Staff I's grasp followed by a brief physical exchange between them as the patient pulled his/her cell phone away from him and as he tried to retrieve the phone. Staff I was then observed stepping back and as the patient was actively engaging with his/her cell phone again, Staff I approached the patient quickly and abruptly removing the cell phone from the patient's hands. The patient in turn jumps up from the stretcher while still being strapped in, removed the buckle, and then lunges himself/herself onto staff as if heading towards Staff I who had taken his/her cellphone. Staff J is then observed holding the patient and Staff I lunges toward the patient. The patient, Staff I, and Staff J end up on the floor and both Staff I and Staff J were observed holding the patient down on the floor.

Multiple staff are observed entering the area including Staff K. The patient is then brought up to his/her feet and escorted by Staff I, Staff J and another staff member. The patient is visibly struggling and fighting against staff and is then observed being tackled onto a patient bed. Staff J was observed holding the patient's left hand in place and at one point is observed placing his hand on the patient's left cheek, guiding the patient's face away from himself. Staff I was observed landing on the bed along with the patient while holding the patient's right hand and arm and straddling his/her right leg with both of his legs. When additional staff intervene, Staff I completely disengages with the patient and the patient is then observed grabbing Staff I's shirt from his right shoulder. Staff I was then observed grasping the patient's right hand and eventually throws himself on top of the patient while she/he is being restrained onto the bed.

During a surveyor interview with Staff E following the review of surveillance footage, she agreed that Staff I escalated the patient by abruptly removing the patient's phone from his/her hands which caused the patient to react aggressively and violently toward staff. Staff E was informed that Staff K's description of the incident, stating that the patient was "tackled" onto a patient bed, was consistent with what was observed on surveillance video substantiating the allegation that excessive force was used during a restraint.

Based on record review and staff interview, it was determined that the application of a restraint was in accordance with the order of a physician after a nurse who reviewed the order failed to ensure that the restraint order was written correctly by the physician according to the type of restraint applied to a patient for 1 of 3 patients reviewed, (Patient ID #13).

Findings are as follows:

The hospital's policy for "Restraint Use" defines "Violent Restraint (Behavioral)" as "Used in emergencies to manage violent/aggressive behavior that may jeopardize the immediate physical safety of the patient, staff, or others. (i.e., punching, hitting ..."

According to the hospital's "Restraint Documentation" protocol for nursing staff, the nurse needs to "ensure that the physician's order for restraint is written correctly according to the type of restraint applied to the patient ..."

Record review revealed that Patient ID #13 became "very excited" and appeared to be "disassociated from reality", was not redirectable and was "speaking unintelligibly", shouting and "under a great amount of stress". The patient then began punching the wall, injured his/her right hand, and attacked staff before being restrained.

According to the record, "keyed" limb restraints were applied to the patient's left wrist and ankles.

Record review revealed that Staff L entered an order for the initiation of restraints due to the potential for self-harm. The order stated that stated, "soft" restraints were to be applied to the patient's ankles and wrists for 24 hours as the patient was interfering with medical devices.
Further record review revealed that Staff M reviewed this restraint order after Staff L entered it into the medical record.

During a surveyor interview on 7/3/2025 at 9:00 AM with Staff M, he indicated that soft restraints are never used on patient that is physically violent and instead "keyed" limb restraints are used. Staff M indicated that he usually ensures that the appropriate restraint order is entered into the medical record according to what is applied to the patient.

During a surveyor interview on 7/2/2025 at 9:15 AM with Staff F, she indicated that she would expect Staff M to ensure that the appropriate restraint order is entered in the medical record for the type of restraint applied to the patient.

Based on record review, policy review, and staff interviews, the hospital failed to ensure that emergency department staff adhered to established policies and procedures regarding the provision of discharge instructions and the review and clarification of new prescriptions in the emergency department for 5 of 8 patients reviewed (ID #s 1, 2, 4, 5, and 6). This failure resulted in one emergency department provider prescribing oxycodone to a patient (ID #1) with a documented allergy to oxycodone. The newly prescribed medication was not included in the discharge instructions for the nurse to review and clarify, and the patient took the medication as prescribed while at home and experienced an adverse drug reaction.

Findings are as follows:

The hospital's policy titled, "Discharge of the ED [Emergency Department] Patient", effective 11/24/2024 states in part:

" ...(5) The discharging nurse will review and clarify discharge orders and any new prescriptions and convey the information to the patient/family.

(6) Discharge instructions will include information regarding care at home, prescriptions and any follow-up visits recommended by the treating ED LIP [Emergency Department Licensed Independent Provider] ..."

On 6/9/2025, The Rhode Island Department of Health received a complaint in which Patient ID #1 alleged they were prescribed Percocet (a medication that contains a combination of oxycodone and Tylenol used to provide relief from pain) upon discharge from the emergency department despite being allergic. The patient alleged that they confirmed their allergy to Percocet with multiple people in the emergency department including a Physician Assistant and was provided with a bright red allergy bracelet. Patient ID #1 indicated they took the medication because she/he thought the generic name on the bottle, oxycodone (a medication used to provide relief from pain), was Vicodin (a medication that contains a combination of hydrocodone and Tylenol used to provide relief from pain).

During a surveyor interview on 7/1/2025 at 9:22 AM with Patient ID #1, she/he revealed that while taking the newly prescribed oxycodone at home, she/he experienced an "itchy/scratchy" feeling in his/her throat as well as "tightening of muscles" in his/her shoulders and throat.
Record review revealed Patient ID #1 presented to the emergency department in June of 2025 with complaints of abdominal pain.

Review of the emergency department documentation revealed a list of allergies which included "Percocet 7.5/325 (a medication that contains a combination of oxycodone and Tylenol used to provide relief from pain) with an associated symptom of "difficulty breathing."

The record indicated that while in triage, the patient's allergies were "reviewed and documented" by Staff A.

Further review of the emergency department documentation revealed that Staff B prescribed the following medications to Patient ID #1 at discharge:

- Oxycodone
- Naloxone (medication used to reverse overdose from narcotics)
- Tylenol (medication used to relieve pain and fever)
- Keflex (antibiotic)
- Zofran (medication used to relieve nausea and vomiting)

Record review of discharge documents ("Patient Visit Summary" and "Emergency Services - Discharge Instructions") provided to the patient upon discharge, failed to reveal evidence that the newly prescribed medications were included in these documents.

During a surveyor interview on 7/1/2025 at 2:15 PM with Staff C, he indicated that in his practice, he does not tell the patient the specific medications they are prescribed upon discharge nor how to take the medication since he does not have visibility of which medications have been prescribed by the provider. Staff C indicated that if the provider were to write the name and dose of the medications prescribed to the patient in the discharge instructions, he would review this information with the patient.

During a surveyor interview on 7/2/2025 at 10:45 AM with Staff B, she indicated she prescribed oxycodone to the patient as the patient was to avoid anti-inflammatories due to their condition and indicated she did not remember discussing the new prescription for oxycodone with the patient. Staff B indicated she typically reviews a patient's allergies, however, does not remember doing so for this patient. Staff B indicated she did not remember getting a warning alert from the system when she entered oxycodone as a newly prescribed medication. When asked what she would do differently, Staff B stated she would not prescribe oxycodone and would prescribe a different medication, such as Norco (a medication that contains a combination of hydrocodone and Tylenol used to provide relief from pain) to help control the patient's pain at home.

During a surveyor interview on 7/1/2025 at approximately 3:00 PM and on 7/2/2025 at approximately 2:00 PM with Staff E, she confirmed that according to Staff F, when a provider enters a new prescription in the medical clinical documentation system in the emergency department, the newly prescribed medication does not populate in the discharge instructions for the nurse to review upon discharge. Staff E then indicated that according to their policy, "Discharge of the ED Patient", new prescriptions are to be discussed and reviewed with patients. In addition, Staff E revealed that Staff B received a warning alert from the clinical documentation system specific to Patient ID #1's allergies when she entered the prescription for oxycodone. She indicated that Staff B overrode the warning alert and selected "defer to provider" as the reason for the override.

During an additional review of patients who were discharged from the emergency department with new prescriptions for the month of June 2025 entered by Staff B and other providers, it was determined that the documents provided to the following patients upon discharge demonstrated noncompliance with hospital policy and inconsistent practice relative to newly prescribed medications.

Record review revealed that Patient ID #2, who presented to the emergency department in June of 2025 due to abdominal pain, was discharged home with a prescription for Zofran and oxycodone per Staff B. However, the Emergency Services- Discharge Instructions and the Patient Visit Summary failed to reveal evidence that the newly prescribed medications were included in these documents for the nurse to review and clarify in accordance with hospital policy.

Record review revealed that Patient ID #4, who presented to the emergency department in June of 2025 due to flank pain and was diagnosed with a kidney stone, was discharged home with a prescription for Augmentin, an antibiotic, per Staff B. However, the Emergency Services- Discharge Instructions and the Patient Visit Summary failed to reveal evidence that this newly prescribed antibiotic was included in these documents for the nurse to review and clarify in accordance with hospital policy.

Record review revealed that Patient ID #5, who presented to the emergency department in June of 2025 due to dental pain, was discharged home with a prescription for Augmentin and oxycodone per Staff B. However, the Emergency Services- Discharge Instructions and the Patient Visit Summary failed to reveal evidence that these newly prescribed medications were included in these documents for the nurse to review and clarify in accordance with hospital policy.

Record review revealed that Patient ID #6, who presented to the emergency department in June of 2025 due to abdominal pain, was discharged home with a prescription for Flomax (a medication used to alleviate difficulty urinating), ketorolac (a medication used to help treat pain), and nitrofurantoin macrocrystals (an antibiotic) per Staff D. However, the Emergency Services- Discharge Instructions and the Patient Visit Summary failed to reveal evidence that these newly prescribed medications were included in these documents for the nurse to review and clarify in accordance with hospital policy.