F0658

E

Failure to Administer and Document Medications and Treatments During Overnight Shift

Central Falls, Rhode Island Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that residents received treatment and care in accordance with professional standards of practice by not following provider orders for medications and treatments during a specific overnight shift. A facility-reported incident dated 1/14/2026 indicated that during the 11:00 PM to 7:00 AM shift on 1/2/2026, a Registered Nurse (Staff A) did not fulfill assigned nursing responsibilities. Record review showed that medication orders were not administered and treatment orders were not completed for 40 of 48 residents reviewed during that shift, covering the period from 11:00 PM on 1/2/2026 into 7:00 AM on 1/3/2026.

Surveyor interviews with the Director of Nursing Services (DNS) and the Administrator on 1/20/2026 revealed that when the oncoming shift identified missing documentation, their initial concern was possible medication diversion by the agency nurse. The only medications documented as administered during the shift were Oxycodone, Ritalin, and Lorazepam, and the DNS and Administrator stated that the nurse’s documentation was inaccurate. They reported that when contacted, the agency nurse refused to return to the facility to complete the documentation. The DNS and Administrator were unable to provide evidence that residents received their ordered medications and treatments in accordance with professional standards of practice during the 11:00 PM to 7:00 AM timeframe in question.