HospitalInspections.org

Based on review of hospital policies, and staff interviews, it has been determined that the hospital failed to provide a safe environment and have mechanisms/methods in place that ensure patients are protected from of all forms of abuse and neglect, including injuries of unknown origin, as evidenced by the failure to protect 1 of 1 patient reviewed who was found to have a fractured tibia and fibula of unknown origin, Patient ID # 1.

Findings are as follows:

Review of the hospital's policy entitled, "Abuse and Neglect-Guidelines for Screening and Intervention," which was last approved on 3/2022 states in part,

"II. POLICY: ...
2. All staff at the [Eleanor Slater Hospital] ESH are responsible to report actual or suspected cases of abuse and/or neglect. The hospital is responsible to evaluate all allegations, observations and suspected cases of neglect, exploitation, and abuse.
3. Staff suspecting abuse or neglect must report suspicions to his/her supervisor. The supervisor is responsible for initiating appropriate actions including notifying his/her supervisor and administration.

Review of the hospital policy titled "Patient Rights and Responsibilities" policy, last approved on 3/2022, states, in part,
IV: Policy Statement Pertaining to Patients' Rights
1. The patient shall be treated with dignity and respect, [and] afforded considerate and respectful care ...
19. The patient has the right to be free from neglect, exploitation, verbal, mental, physical, and sexual abuse..."

Review of the record for Patient ID #1, revealed that s/he was admitted to the hospital in 1999, and has diagnoses which includes infantile autism with profound developmental delay, insulin dependent diabetes with suspected neuropathy, seizure disorder, vitamin D deficiency, obesity, and persistent bilateral lower extremity edema.

Additional record review reveals s/he has ongoing issues with fluid retention (edema), swelling in various parts of his/her body. The patient is non-verbal and only has the ability to move his/her upper extremities on a very limited basis and is unable move his/her lower extremities. The patient requires total assistance with all personal care, ADLs including repositioning in bed, feeding, and incontinence care.

Review of the Physician orders reveals an order for Ted's (anti-embolic) stockings. Review of the patients Plan of Care states Ted's are applied in the morning and removed every night with hygiene care.

According to documentation, on 12/28/2024 during the 11PM -7AM shift, the Nursing Assistant, Staff A, while providing care to the patient, at approximately 2:20 AM, staff noticed the right ankle swollen with a protrusion. Staff A and Nursing Assistant, Staff E informed the Nurse, Staff F who notified the On-Call Physician. The On-Call Physician came in to assess the patient.

Review of the ESH On-Call Physician's note dated 12/28/2024 at 3:15 AM, stated staff had reported the area of redness and "protrusion" to his/her lateral right ankle. The progress note stated there was swelling for the past month and indicated "Right ankle swelling and edema, possible deformity, small soft red to lateral right malleolus. Concern for possible subacute fracture to ankle, x-ray ordered in the AM." On 12/29/2024 at 10:50 AM the patient was transferred to Landmark Medical Center for further evaluation of the right ankle.

A review of the medical records from Landmark Medical Center dated 12/28/2024 revealed "the patient has a confirmed fracture of the distal tibia and fibula, which was confirmed by x-ray. The record indicates "the facility has no idea as to what happened to the patient." The x-ray report reveals the patient had a closed fracture of distal tibia and fibula, "concern is that the distal fibular is likely osteoporotic, causing deterioration to the medial malleolus, possible pathological fracture however mechanical fracture seems to be more consistent."

During an interview with Eleanor Slater Hospital Nursing Assistant, Staff I, on 1/6/2025 at 9:50 AM, she stated that she worked on 12/27/2024 and that at 7:00 PM she and another nursing assistant put the patient back to bed. She removed the Ted's stockings, and noticed the patient had some swelling, but nothing different than what s/he has been having for quite a while. She stated there was no protrusion or deformity noted at that time.

During an interview with ESH Staff A, at 3:15 PM on 1/6/2025, who had worked on 12/28/2024, the 11-7 AM shift, stated that when she went in to do rounds around 2:00 AM, that the patient's pressure relief boot was on the floor. She looked at the patient's ankle and noticed a swollen area that looked like bone. She asked the other nursing assistant to look at it and they went and reported it to the Nurse, Staff F. She informed the surveyor that staff had been having trouble putting on the patient's Ted's stockings due to the edema. She stated that this was reported this to the Nurses, but because they had a doctor's order, the patient needed to have the Ted's on.

During an interview with ESH Nurse Manager, Staff J, on 1/6/2025 at approximately 11:30 AM, stated that she was aware of the patient having an order for the Ted stocking and that she had obtained an order to discontinue them on 12/31/2024 at 12:00 PM, after the patient was diagnosed with a fracture. She acknowledged they are difficult to put on when patients have edema.

During an interview with the ESH Risk Manager on 1/7/2025 at approximately 11:15 AM. she stated that when she initially reported the incident to the Rhode Island Department of Health, She acknowledged that she had not directly interviewed staff, but states she had collected statements from multiple staff all of which denied knowledge of the injury, or how a patient may have sustained the injury.

During an interview with the ESH Podiatrist who had seen the patient on 1/7/2025 at 10:30 AM and had reviewed the Landmark Hospital Emergency Department report and stated he believes that the patient sustained some sort of injury, since there are two fractures, both a tibia and a fibula fracture.