Citations in Rhode Island
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Rhode Island.
Statistics for Rhode Island (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Rhode Island
A resident with RLS and seizures, who was cognitively intact, had a physician’s order for pramipexole twice daily that was not followed when nine doses were missed over several days because the medication was unavailable. The MAR documented multiple omitted morning and afternoon doses, and the resident reported going several days without the drug, experiencing leg discomfort, pain radiating to the back, and pacing due to inability to sit still. A provider note indicated the pharmacy failed to deliver the medication and that the resident requested ED transfer to obtain it. The DON acknowledged the medication was not given as ordered due to unavailability, and the pharmacy account manager reported that the facility did not submit the refill request until several days after doses began to be missed.
The facility did not follow physician orders for scheduled weights and failed to implement its own reweigh policy for significant weight changes in two residents. One resident with hemiplegia, hemiparesis, and adult failure to thrive did not have monthly weights obtained as ordered, and multiple documented weight losses were not rechecked within the required timeframe. Another resident with type 2 DM experienced repeated large weight gains without any documented confirmation weights, despite facility policy requiring reweighs for substantial changes. The Dietitian and DON acknowledged that ordered weights and required reweights were not completed or could not be verified in the clinical record.
A resident with Alzheimer's disease and cardiac comorbidities was actively dying and experiencing increased pain and agitation when a hospice RN recommended more frequent scheduled and PRN Morphine and Ativan for end-of-life comfort. An RN texted these recommendations to the physician, who approved them, but the new orders were never entered on the MAR or implemented. As a result, only the prior, less frequent PRN and TID Lorazepam and PRN Morphine orders remained active, and the last doses of Ativan and Morphine were administered many hours before the resident's death. The physician later stated the nurse should have implemented the hospice recommendations, and the DON acknowledged the resident did not receive the comfort medications as ordered.
A resident on hospice with Alzheimer’s disease, hypertension, and coronary artery disease experienced apnea, tachycardia, pain, and agitation near end of life. Hospice recommended increasing scheduled Morphine and Ativan to Q2H with additional PRN dosing Q1H for breakthrough symptoms, but facility records showed these recommendations were not communicated to the physician or implemented. The MAR reflected the last Morphine and Ativan doses were given many hours before the resident’s death, and there were no nursing progress notes documenting assessment of the resident’s condition during the final hours, despite facility policy requiring communication with hospice, adherence to hospice interventions, and ongoing monitoring. The DON confirmed the resident did not receive medications per hospice recommendations and that ongoing monitoring was not documented.
A resident with a UTI and care plan directives for sepsis screening and reporting of changes in VS and mental status experienced confusion, attempts to get out of bed, removal of nasal cannula, SOB, and decreased O2 saturation during the night shift. The assigned RN increased O2 from 1 L to 4 L but did not notify a provider, document the event, or clearly communicate the change in condition, stating she did not recognize it as a change and did not know the resident’s baseline. On the next shift, another RN found the resident less alert, unable to follow simple commands or form words, with tachycardia and O2 saturation of 93% on 4 L, notified the NP, and, together with the unit manager and another RN, arranged non-medical transport rather than EMS to the hospital. The resident arrived at the hospital via non-medical transport with AMS, SOB, and severe hypoxia, was diagnosed with hypercarbic hypoxic respiratory failure, sepsis, and influenza, and later died. Record review showed no completed competencies for four RNs on identifying changes in condition, and the DON could not provide evidence of education on this topic, while the Medical Director stated he expected decreased O2 saturation to be treated as a change in condition and that EMS should transport residents with such changes.
A resident with a history of orthostatic hypotension and autonomic nervous system disorder was inadvertently given another resident’s medications during a morning med pass while an RN was training a newly hired LPN. The RN prepared multiple drugs intended for a roommate with Parkinson’s disease, DM, HTN, CAD, and depression, including two antihypertensives, an antidiabetic, an antiplatelet, an antiparkinsonian agent, an antidepressant, and vitamins, and handed them to the LPN to administer. The LPN entered the shared room, identified both residents, but administered the prepared medications to the wrong resident, then later disclosed the error when returning with the correct medications. Following the error, the affected resident’s BP progressively dropped, the resident became pale and weak, and was transferred and admitted to the hospital with hypotension, as confirmed by hospital records and acknowledged by the DON.
A resident with a UTI and an order for IV Meropenem every eight hours did not receive three scheduled doses, and there was no evidence the provider was notified of the missed antibiotics. The resident, who was on 1 L O2 via nasal cannula, later exhibited confusion, removal of the nasal cannula, shortness of breath, and decreased O2 saturation requiring an increase to 4 L O2, but the night RN did not document these findings, did not recognize them as a change in condition, and did not notify a provider. Oncoming staff then found the resident with decreased alertness, tachycardia, and continued increased O2 needs, notified the NP, and arranged transfer to the ED via non-medical transport rather than EMS, despite altered mental status and hypoxia. Hospital records documented arrival with altered mental status, severe hypoxia, hypercarbic hypoxic respiratory failure, sepsis, and influenza, and the resident expired later that day; the Medical Director and family interviews confirmed expectations and misunderstandings regarding antibiotic administration, change-in-condition reporting, and the choice of non-medical transport.
A resident admitted with a UTI had hospital discharge orders and corresponding facility orders for Meropenem 1 g IV in 50 mL NS three times daily for several days, but three doses were missed. Nursing staff did not administer the antibiotic despite Meropenem and 100 mL NS being available in the IV E‑kit, stating they believed they could not give the medication without a 50 mL NS bag and did not contact the pharmacy for clarification. E‑kit utilization records showed no Meropenem or NS was removed, and documentation did not show that a provider was notified of the missed doses. The resident was later transported to the hospital, where they were found to have hypercarbic hypoxic respiratory failure, sepsis, and influenza, and subsequently died after being placed on comfort measures.
Two residents’ rights to dignity, preferences, and privacy were not honored when a NA allegedly provided rude care, failed to follow a dependent resident’s expressed instructions for safe rolling in bed, left the privacy curtain open during personal care, and the resident’s head struck a side rail resulting in a bruise and head pain. In a separate incident, a cognitively intact resident with longstanding anxiety and panic around dogs experienced distress when a visitor’s dog was brought into a common area without prior consent, and the Director of Social Services told the resident to leave the area rather than addressing the resident’s request to remove the dog, contrary to facility policy requiring that patients be asked if they wish to interact with animals.
A resident with a complicated UTI had an order for Meropenem 1 gm IV three times daily in normal saline. Although Meropenem and normal saline were listed as available in the IV E-kit, review of the E-kit utilization form showed they were not removed for use, and pharmacy records indicated the medication was not delivered until the following evening. The resident missed three ordered doses, yet the February MAR showed Meropenem as signed out and documented as administered for two of those times when it had not been given. The DON confirmed the medication was not administered until after pharmacy delivery and could not show that the MAR accurately reflected the missed doses.
Failure to Ensure Timely Refill and Administration of Pramipexole for RLS
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of pramipexole for a resident with restless leg syndrome (RLS) and seizures. The resident was admitted in January 2026 and had intact cognition, as evidenced by a Brief Interview for Mental Status score of 15 out of 15. A physician’s order dated 1/23/2026 directed that pramipexole dihydrochloride 0.5 mg, two tablets by mouth twice daily, be administered for RLS. Review of the February 2026 Medication Administration Record showed that this medication was not administered as ordered on nine occasions between 2/8/2026 and 2/12/2026, with doses missed on multiple mornings and afternoons. The resident reported going about three days without receiving pramipexole because it was not available, and stated that this resulted in uncomfortable leg sensations, pain radiating to the back, and the need to pace around the unit due to discomfort when sitting still. A progress note dated 2/11/2026 documented that the pharmacy failed to deliver the ordered pramipexole and that the resident requested transfer to the Emergency Department to access the medication. During interviews, the Director of Nursing Services acknowledged that the medication was not administered as ordered on the identified dates because it was unavailable from the pharmacy, and the Pharmacy Account Manager stated that the refill request for pramipexole was not submitted by the facility until 2/12/2026.
Failure to Follow Physician Orders and Reweigh Policy for Significant Weight Changes
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician orders and its own weight assessment policy for multiple residents. For one resident with hemiplegia, hemiparesis, and adult failure to thrive who was readmitted in October 2025, physician orders required monthly weights beginning in August 2025 and weekly weights for four weeks starting in January 2026. The clinical record showed weights documented in September, November, January, and February, but there was no evidence that weights were obtained in October and December as ordered. During interviews, the Dietitian and the Director of Nursing Services acknowledged that the ordered weights for this resident in October and December 2025 could not be verified. The facility also failed to follow its policy titled “Weight Assessment and Interventions,” which requires that any weight change of 5 lbs in a month or 3 lbs in a week be rechecked within 72 hours for confirmation and verified by nursing. For the first resident, the record showed a 13.4 lb loss between early November and early January, a 3.8 lb loss between early and mid-January, and a 4.2 lb loss between late January and mid-February, with no documentation that any of these weights were rechecked. For a second resident admitted in November 2025 with type 2 diabetes mellitus and ordered to have weekly weights for four weeks, the record showed multiple significant weight gains between early November and early February, including gains of 7.8 lbs, 10.4 lbs, 7.8 lbs, and 6 lbs between successive weigh dates, without evidence of required reweights. The Dietitian confirmed that reweights were not obtained per policy for these residents, and the Director of Nursing Services was unable to provide documentation of the required reweights.
Failure to Implement Hospice-Recommended End-of-Life Comfort Medication Orders
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when hospice-recommended end-of-life comfort medication orders were not implemented. The resident, admitted with diagnoses including Alzheimer's disease, hypertension, and atherosclerotic heart disease, was declining and experiencing increased pain and agitation. A hospice RN assessed the resident in the late afternoon and recommended scheduling Morphine concentrate 5 mg every 2 hours and Ativan (Lorazepam Intensol) 0.5 mg every 2 hours, with PRN orders for both medications every hour for breakthrough pain or agitation. At the time of the resident's death, the MAR still reflected prior orders: Lorazepam Intensol 0.25 ml three times daily, Lorazepam Intensol 0.25 ml every 2 hours PRN for restlessness, and Morphine sulfate 0.25 ml every 2 hours PRN for pain greater than 4, with no evidence that the hospice recommendations had been entered or activated. The RN on duty stated she texted the new hospice recommendations to the resident's physician, and the surveyor verified a text message indicating new hospice recommendations for scheduled and PRN every 1-hour Ativan and Morphine, to which the physician responded "ok." However, the RN could not provide evidence that the orders for scheduled every-2-hour Morphine and Ativan or the hourly PRN orders were ever implemented. The resident's physician indicated that the nurse should have implemented the hospice recommendations after they were approved. MAR review showed the last dose of Ativan was given at 10:00 PM the night before death and the last dose of Morphine at 2:13 PM the previous afternoon, approximately 8 and 16 hours, respectively, before the resident died at 6:17 AM. The DON acknowledged that the resident did not receive Ativan and Morphine as ordered for end-of-life comfort.
Failure to Implement Hospice End-of-Life Recommendations and Monitor Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that hospice services met professional standards and that hospice recommendations were communicated, implemented, and documented for a resident receiving end-of-life care. The resident, admitted in January 2026 with diagnoses including Alzheimer’s disease, hypertension, and atherosclerotic heart disease of the native coronary artery, was on hospice services. A facility policy titled “Coordination of Hospice Services Policy” stated that the facility would communicate with hospice, identify and follow all interventions put into place by hospice and the facility, monitor medications and medical supplies provided by hospice as indicated in the plan of care, and provide ongoing monitoring of resident conditions. On 1/30/2026, hospice documentation showed that during an end-of-life visit between 4:00 PM and 5:00 PM, the hospice RN assessed the resident as having periods of apnea, a racing pulse, increasing pain, and agitation, with any movement causing groaning and grimacing. The hospice RN recommended scheduling Morphine concentrate 5 mg every 2 hours and Ativan concentrate 0.5 mg every 2 hours, with PRN orders for Morphine 5 mg every hour and Ativan 0.5 mg every hour for breakthrough symptoms. Record review revealed that earlier on 1/30/2026 at 11:55 AM, facility staff had spoken with hospice about the resident’s respiratory rate of 30 and restlessness and received a recommendation to increase the frequency of PRN medication from every 4 hours to every 2 hours, which the physician approved. However, further review of the clinical record, including progress notes, physician’s orders, and the MAR, failed to show that the additional hospice recommendations from the late afternoon end-of-life visit were communicated to the physician or implemented. The MAR showed the last dose of Ativan was given at 10:00 PM on 1/30/2026 and the last dose of Morphine at 2:13 PM on 1/30/2026, approximately 8 and 16 hours, respectively, before the resident’s death at 6:17 AM on 1/31/2026. Additionally, there were no nursing progress notes documenting assessment of the resident’s condition between 11:55 AM on 1/30/2026 and the time of death, despite the facility policy requiring ongoing monitoring. During interview, the DON acknowledged that the resident did not receive Morphine and Ativan per hospice recommendations and that there was no evidence of ongoing monitoring of the resident’s condition at end of life.
Failure to Ensure RN Competency in Identifying Change in Condition and Appropriate Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff had the competencies and skills to identify and respond to a resident’s change in condition, as required by facility policy and the facility assessment. The facility’s Nursing Services policy required sufficient nursing staff with appropriate competencies to assure patient safety and to identify changes in condition, including use of tools and documentation systems such as Point of Care/PointClickCare to trigger alerts. The facility assessment stated that all staff were educated, trained, and competency-checked on hire and annually, including on practices and tools used to identify resident changes in condition. However, record review showed no evidence that competencies related to identifying a change in condition had been completed for four RNs (Staff B, C, D, and Unit Manager F). The resident involved had been admitted with diagnoses including a urinary tract infection (UTI) and had a care plan that directed staff to screen for sepsis and report a positive screen to a physician, including when two or more criteria such as pulse greater than 100, respiratory rate greater than 20 or oxygen saturation at or below 90%, or altered mental status were present. The care plan also required staff to report to the physician any changes in vital signs and/or condition, including subtle changes. During the 11:00 PM to 7:00 AM shift, RN Staff B found the resident confused, attempting to get out of bed, with the nasal cannula removed, short of breath, and with decreased oxygen saturation. Staff B increased the oxygen flow to 4 L, after which the oxygen saturation improved, but she did not notify a provider, stating she did not consider this a change in condition and was unaware of the resident’s baseline. She reported only that the oncoming nurse should “keep an eye” on the resident and did not document or otherwise communicate in the clinical record that the resident had been without the nasal cannula, required increased oxygen, and was trying to get out of bed unassisted. On the following shift, RN Staff C documented a change from the resident’s baseline, including decreased alertness, inability to follow simple commands or form words, and vital signs showing blood pressure 119/94, heart rate 126, respiratory rate 20, and oxygen saturation 93% on 4 L oxygen. Staff C contacted the nurse practitioner, who ordered the resident sent to the emergency department, and Staff C, along with Unit Manager RN Staff F, RN Staff D, and the nurse practitioner, decided to send the resident via a non-medical transport company rather than emergency medical services. The Continuity of Care Acute Care Transfer Form completed by Staff C indicated the resident was unable to form sentences, required increased oxygen, was unable to follow simple commands, and had a mental status change. Hospital records showed the resident arrived via non-medical transport with altered mental status, shortness of breath, and severe hypoxia, and was diagnosed with hypercarbic hypoxic respiratory failure, sepsis, and influenza, and later expired that day. The Medical Director stated he would expect a decrease in oxygen saturation to be identified as a change in condition with provider notification, and that emergency medical services should transport a resident experiencing a change in condition. The DON was unable to provide evidence that Staff B, C, D, and F had received education on identifying and addressing a resident’s change in condition.
Significant Medication Error During Training Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when one resident was inadvertently administered multiple medications prescribed for a roommate. The facility’s Medication Administration Safety Program policy required that the same person who prepares medications must administer them and that the licensed staff member must confirm the resident’s identity prior to administration. On the date of the incident, RN Staff A was training newly hired LPN Staff B during the morning medication pass and prepared a set of medications at the cart for Resident ID #2, including two antihypertensives, an antidiabetic, an antiplatelet, an antiparkinsonian agent, an antidepressant, a multivitamin, and two additional vitamins. Resident ID #1 had been admitted in January 2026 with diagnoses including orthostatic hypotension, autonomic nervous system disorder, and thrombocytopenia. Resident ID #2 had been admitted in July 2025 with diagnoses including Parkinson’s disease, diabetes mellitus, high blood pressure, major depressive disorder, and coronary artery disease. After RN Staff A prepared Resident ID #2’s medications and handed them to LPN Staff B with instructions to administer them to Resident ID #2, Staff B went into the shared room, identified both residents, but proceeded to administer the medications intended for Resident ID #2 to Resident ID #1 instead. Staff B then returned to the medication cart, where RN Staff A had prepared Resident ID #1’s medications, and both staff re-entered the room to administer those medications. At that time, LPN Staff B informed RN Staff A that Resident ID #1 had already received the medications intended for Resident ID #2. Subsequent nursing documentation showed that immediately after the error was identified, Resident ID #1’s blood pressure was 99/61, and later readings declined to 78/40 and then 63/37, with the resident becoming pale and weak. The resident’s condition required transfer to the hospital, where continuity of care documentation indicated arrival to the emergency department with hypotension, dizziness, and lightheadedness, and the need for IV fluid boluses for systolic blood pressure readings in the 80s. The DON acknowledged during interview that Resident ID #1 inadvertently received Resident ID #2’s medications and was admitted to the hospital with hypotension as a result.
Failure to Administer Ordered IV Antibiotics, Recognize Change in Condition, and Arrange Appropriate Medical Transport
Penalty
Summary
The deficiency involves the facility’s failure to administer ordered IV antibiotics, recognize and document a change in condition, notify a provider of that change, and arrange appropriate medical transport for a resident who was ultimately hospitalized and expired. The resident had been admitted with diagnoses including a UTI and had a care plan intervention to screen for sepsis and report positive screens or changes in vital signs and condition to a physician. A hospital discharge summary ordered Meropenem 1 g IV every eight hours for six days and documented that the resident was alert and oriented and receiving 1 L O2 via nasal cannula. Record review showed that three scheduled doses of Meropenem were not administered as ordered, and there was no evidence that the provider was notified of the missed doses. On one evening, progress notes documented the resident as alert and oriented x3 with O2 saturation at 91% on oxygen via nasal cannula and a pulse of 96. During interview, the RN on the 11 PM–7 AM shift (Staff B) stated she found the resident confused, attempting to get out of bed, with the nasal cannula removed, short of breath, and with decreased O2 saturation. She reported increasing the oxygen flow from 1 L to 4 L, after which the O2 saturation improved, but she did not notify the provider because she did not consider this a change in condition and was unaware of the resident’s baseline. She also stated she told the oncoming nurse to keep an eye on the resident. The clinical record did not contain documentation that the resident had been found without the nasal cannula, that oxygen flow had been increased to maintain saturation, or that the resident was trying to get out of bed unassisted, and there was no documented communication of these findings to oncoming staff. The oncoming RN (Staff C) documented that, later that morning, the resident had a change from baseline with decreased alertness, inability to follow simple commands or form words, and vital signs including BP 119/94, HR 126, RR 20, and O2 saturation 93% on 4 L O2. Staff C contacted the NP, who ordered the resident sent to the ED for evaluation, and transport was arranged with a non-medical transportation company. The Continuity of Care Acute Care Transfer Form completed by Staff C indicated the resident was unable to form sentences, required increased oxygen, was unable to follow simple commands, and was experiencing a mental status change. The NP (Staff E) stated she was notified of the altered mental status and decreased O2 saturation and ordered the transfer but did not assess the resident in person, and she stated she would have expected the resident to be transported per facility policy for such a situation. The DNS reported there was no policy specifying the type of transportation for a resident with a change in condition and that mode of transport was considered a clinical decision. Hospital documentation showed the resident arrived via non-medical transport with altered mental status, shortness of breath, and severe hypoxia, and was found to have hypercarbic hypoxic respiratory failure, sepsis, and influenza, and was transitioned to comfort measures and expired later that day. The Medical Director stated he would have expected IV antibiotics to be administered as ordered or the provider to be notified of missed doses, and that a decrease in O2 saturation should be identified as a change in condition with provider notification. He also stated he would have expected EMS transport for a resident with a change in mental status and decreased O2 saturation and reported being told that the family refused EMS because they wanted a specific hospital. The DNS stated the family member chose non-medical transport after being educated that non-medical transport could not provide medical support, while the family member stated they did not choose the mode of transportation, believed the transporters were EMTs, were not informed that the resident would not be monitored during transport, and were not made aware of the missed antibiotic doses. The facility’s failures included: not administering three ordered doses of IV Meropenem and not notifying the provider of these missed doses; not identifying and documenting the resident’s nighttime confusion, removal of nasal cannula, shortness of breath, decreased O2 saturation, and need for increased oxygen as a change in condition; not notifying the provider at that time; and arranging non-medical rather than emergency medical transport for a resident with altered mental status, increased oxygen needs, and decreased O2 saturation. These failures were cited as placing the resident at risk for serious injury, serious harm, serious impairment, or death and were cross-referenced to F695, F726, F760, and F842.
Failure to Administer Ordered IV Antibiotic Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when ordered IV antibiotic therapy was not administered as prescribed. The resident was admitted with a diagnosis that included a UTI and had a hospital discharge order for Meropenem 1 g in 50 mL normal saline IV every eight hours for six days. The facility’s physician order reflected Meropenem IV 1 g in 50 mL normal saline three times a day for a complicated UTI through a specified end date. Record review showed the resident missed three doses of the ordered Meropenem IV. The facility had received a complete IV E‑kit that contained Meropenem IV 1 g vials and 100 mL normal saline, and the PharMerica Genesis Master E‑Kit Contents List confirmed these items were available. During interviews, an RN reported she did not administer the antibiotic because it was not available in the exact 50 mL normal saline bag specified, despite knowing Meropenem and 100 mL normal saline were present in the E‑kit. She stated she asked the Unit Manager RN how to administer the medication and was told it could not be given without the correct size saline bag. The pharmacist confirmed Meropenem IV 1 g was available in the E‑kit and stated he would have expected the facility to call the pharmacy to clarify use of the 100 mL normal saline. The IV E‑kit utilization form showed no evidence that Meropenem or normal saline was removed from the kit, and the electronic shipping manifest showed that Meropenem and 50 mL normal saline from the pharmacy did not arrive until later. The DON and Medical Director both acknowledged that Meropenem IV 1 g and 100 mL normal saline were available in the E‑kit and that three doses were missed, and there was no documentation that a provider was notified of the missed doses. The resident was later sent to the hospital after missing three of five doses of the IV antibiotic and was diagnosed there with hypercarbic hypoxic respiratory failure, sepsis, and influenza, and subsequently expired after being transitioned to comfort measures.
Failure to Honor Resident Preferences, Privacy, and Anxiety Related to Care and Pet Visits
Penalty
Summary
The deficiency involves the facility’s failure to honor resident rights to dignity, preferences, and privacy during care for two residents. One resident, admitted with muscle weakness and osteoarthritis and care planned as dependent for ADLs including rolling in bed, reported that a nursing assistant was rude, did not follow the resident’s expressed preferences for how to be safely rolled, and refused to close the privacy curtain during care. The resident, who had a BIMS score of 11 indicating moderately impaired cognition but was alert and oriented, stated that because the nursing assistant did not follow the resident’s instructions on how to be turned, the resident’s head struck the bed side rail. The DNS’s assessment documented a faint bruise above the resident’s left eyebrow, approximately the size of a quarter, and the MAR showed the resident received acetaminophen for head pain following the incident. The same incident included a failure to provide privacy during personal care. The resident reported that the nursing assistant refused to close the privacy curtain despite the resident’s roommate needing to walk past the bed to access the bathroom. The roommate confirmed being present in the room, hearing the nursing assistant speak rudely to the resident, hearing the resident yell “ouch,” and observing that the privacy curtain remained open while care was being provided. The facility’s own policy on resident rights requires that each resident be treated with respect and dignity and that resident goals, preferences, and choices be incorporated into care, but the DNS could not provide evidence that these rights were protected and promoted for this resident. A second deficiency involved the facility’s handling of a resident’s anxiety and panic related to dogs in a common area. A cognitively intact resident with a BIMS score of 15 reported having extreme anxiety and panic around dogs since childhood. The resident stated that another resident’s wife brought a dog into a common area without prior notice, which caused the resident to panic, and that when the resident requested removal of the dog, the visitor initially did not remove it. The resident further reported that the Director of Social Services told the resident to leave the common area if uncomfortable with the dog and refused to continue the discussion. In an interview, the Director of Social Services confirmed telling the resident to leave the common area because other residents had the right to enjoy the dogs and acknowledged not allowing the conversation to continue. The DNS stated that if only one resident was uncomfortable with a dog, that resident would be removed rather than the dog, and could not provide evidence that the facility protected and promoted this resident’s rights, despite a facility policy requiring that patients be asked if they would like to visit or interact with animals.
Incomplete and Inaccurate Documentation of IV Antibiotic Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to IV medication administration for a resident admitted with a diagnosis that included a urinary tract infection (UTI). The physician ordered Meropenem 1 gm IV three times a day in 50 mL of normal saline for a complicated UTI, to continue until 2/10/2026. Record review showed that the facility received a complete IV E-kit on 2/4/2026, and the PharMerica Genesis Master E-Kit Contents List indicated that Meropenem 1 gm vials and 100 mL normal saline were available in the IV kit. However, review of the IV E-kit utilization form did not show that Meropenem or normal saline had been removed from the E-kit for administration. Further record review and pharmacy documentation revealed that Meropenem and 50 mL normal saline were not delivered by the pharmacy until the evening of 2/5/2026 at 8:54 PM, and the resident missed three ordered doses of Meropenem IV 1 gm. Despite this, the February 2026 Medication Administration Record (MAR) showed Meropenem IV 1 gm as signed out and documented as administered on 2/4/2025 at 10:00 PM and on 2/5/2025 at 6:00 AM, when it had not actually been given. During an interview, the Director of Nursing Services acknowledged that Meropenem and 100 mL normal saline were available in the E-kit, that the medication was not administered until it was delivered by the pharmacy on 2/5/2026, and that she could not provide evidence that the MAR accurately reflected the three missed doses.
Some of the Latest Corrective Actions taken by Facilities in Rhode Island
Explore Popular Searches
