HospitalInspections.org

Based on record review and staff interviews it has been determined that the hospital failed to follow the hospital's policy titled "Patient Supervision Levels Policy and Patient Supervision Levels Procedure" revised on 7/2023, for 1 of 3 patients, Patient ID #1 who went outside unsupervised by staff in a motorized wheelchair and sustained an injury.

Findings are as follows:

Review of the hospital's policy and procedure titled "Patient Supervision Levels Policy & Procedures" states in part,

"Policy
1. Supervision levels ordered for patients represent the extent of routine liberty assigned to each patient ...
Supervision Level B- Patients are always supervised ...
The patient does not have the ability to care for self...

B. Procedure ...

7. b Supervision level B: The patient may leave the unit with supervision. The provider will write the order for this level, the number and discipline of those accompanying the patient the destination, and time allowed off the unit."

Record review for Patient ID#1 revealed the patient was admitted on 3/27/2025. The patient is not ambulatory and uses a Hoyer lift for all transfers. S/he uses a motorized wheelchair for mobility and is a supervision level B status which requires a patient to be "always supervised".

On 7/26/2025 the patient went outdoors in his/her motorized wheelchair without staff supervision and was injured.

A review of Patient ID #1's physician orders dated 7/16/2025 identified the following orders: "activity OOB no more than 1 hour each time BID (twice a day), ...may attend therapeutic recreation and off unit activity".

A review of the hospitals the "Off Unit Leave Monitoring Sheet" dated 7/26/2025 identified the following:
Patient ID #1 was signed out of the building at 1:40 PM and returned to the hospital at 2:35 PM. The monitoring sheet identified the patient was "outside".

A review of the hospital's surveillance video of the patient exiting and re-entering the hospital for 7/26/2025, revealed the following:
-Patient ID #1 at 1:35 PM exiting the hospital in a motorized wheelchair accompanied by a family member. The patient was noted to be wearing prevalon protective pressure relief boots on both feet.
-At 2:36 PM the patient returned inside the hospital and is observed in the elevator. The prevalon protective boots are noted only attached to the patients lower legs and not around the patients feet as they are intended. The wheelchair appeared to be stuck, and blood was noted on the floor below the chair. A Nurse, Staff F is observed on the video trying to assist the patient, Nurse, Staff G enters the elevator, and the two nurses are noted to tilt the chair back, and a nursing assistant was able to release the patient's injured foot from under the chairs footrest where it was noted to be trapped.

During an interview with Nurse, Staff F on 8/27/2025 at 3:45 PM, he stated he saw the patient's spouse bending down in front of chair and asked if they needed help. He said there was a considerable amount of blood on the floor, but he couldn't see where it was coming from. He said he called for the doctor who responded. After physician examination, the patient was emergently sent to Rhode Island Hospital via EMS.

During an interview with the Risk Manager, Staff B on 8/28/2025 at 11:45 AM, he was unable to explain why the patient was allowed to go outside without staff supervision as required and could not produce evidence that the hospitals policy related to patient supervision was followed.