F0609

D

Failure to Timely Report Alleged Abuse to State Authorities

Warwick, Rhode Island Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that an alleged violation involving abuse was reported immediately, and no later than two hours after the allegation was made, as required by its policy and state reporting requirements. The facility’s policy dated 8/2020, titled “Reporting Patient Abuse,” states that any person who has reason to believe a patient has been abused should contact the charge nurse, DNS, and/or Administrator at the time of the incident, and that the incident will be reported to the Department of Health within two hours. For one resident reviewed for abuse, the clinical record showed that the resident complained that a nursing assistant was too rough during care on the 3:00 PM to 11:00 PM shift, including twisting the resident’s arms while pivoting from chair to bed. A subsequent skin check identified a small blue mark on the resident’s right outer thigh of unknown etiology.

A nursing progress note dated 3/4/2026 at 6:22 AM, authored by an RN, documented that the resident complained that the nursing assistant was being too rough and did not want that staff member to care for them any longer. The RN stated she would speak to the DNS about the allegation but later revealed she did not report the allegation of abuse to the DNS. Another RN, who had been off work for several days and returned on 3/5/2026, reviewed the resident’s progress notes and, after seeing the documented allegation, reported it to the state health department. The facility-reported incident was submitted to the Rhode Island Department of Health on 3/5/2026 at 1:39 PM, which was not within the required two-hour timeframe from when the allegation was made. During interview, the Administrator was unable to provide evidence that the allegation of abuse had been reported immediately or within two hours after it was made.