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
Surveyors found that the main kitchen failed to follow professional food safety standards, with mold present in the walk-in refrigerator, dirty storage racks, and food items that were past discard dates or improperly labeled. Additional issues included leaking juice containers and broken eggs, all of which were acknowledged by the Food Service Director and Administrator as not meeting required standards.
A resident with hypotension did not receive Midodrine as ordered for multiple low blood pressure readings, and prescribed wound care for the resident's left posterior calf was not completed on one occasion, with documentation indicating the resident was sleeping. Both failures were acknowledged by nursing staff and the DON.
A resident with atrial fibrillation and hypotension received Metoprolol Tartrate despite consistently low blood pressure readings, after medication administration parameters were inadvertently removed from the order. Staff administered the medication without holding it for low systolic BP as originally directed, resulting in the resident receiving unnecessary medication.
A resident receiving Warfarin for deep vein thrombosis did not receive two scheduled doses after a PT/INR test, due to a lack of documentation of test result review and absence of a new Warfarin order. The Coumadin Alert order, which helps ensure proper medication administration, was not transcribed until several days later, and staff confirmed the missed doses and documentation gaps.
A resident with altered mental status and seizures was not treated with dignity when a nursing assistant commented on their odor in their presence and later covered the resident's consented video monitoring device with a pillow. The DON confirmed these actions and could not provide evidence that the resident's rights to respect and electronic monitoring were upheld.
A resident with a gastrostomy, requiring Enhanced Barrier Precautions (EBP), received care from two nursing assistants who did not wear gowns as mandated by facility policy. Despite clear signage and staff awareness of EBP requirements, video evidence and staff interviews confirmed non-compliance with gown use during high-contact care activities. The DON could not provide documentation of an effective infection control program related to EBP for this resident.
A resident admitted with sepsis and a surgical wound did not receive prescribed wound care for several days after admission, despite clear instructions in the hospital discharge documents. Staff interviews confirmed that the wound care orders were not implemented until days after admission, and the DON could not provide evidence of timely treatment.
A resident with severe respiratory and cardiac conditions was transferred to the hospital with another resident's medical record and identifiers after an LPN misidentified the patient and failed to follow protocol for reporting a change in condition. The hospital treated the resident under the wrong information for several hours, and the DON could not provide evidence of the LPN's competency with acute condition protocols.
A resident experiencing severe respiratory distress was emergently transferred to a hospital with another resident's identifiers and medical record due to an LPN's error. The resident received care under the wrong identity for several hours, and the hospital contacted the wrong representative for consent for intubation. The DON confirmed the error and the resident's history of respiratory compromise.
The facility did not ensure consistent and comprehensive care plans for two residents with complex transfer and fall prevention needs. Documentation across care plans, Kardex, physician orders, SPH evaluations, and NA assignments contained conflicting information about required transfer assistance, leading to confusion among staff. Interviews with LPNs, NAs, and the DON confirmed that transfer instructions were not consistently communicated or documented.
Failure to Maintain Food Safety Standards in Main Kitchen
Penalty
Summary
Surveyor observation, record review, and staff interviews revealed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specific findings included the presence of mold on the walk-in refrigerator walls, dirty racks where food was stored, and food with mold that reportedly went unnoticed for weeks. During a kitchen tour, surveyors observed multiple food items in the walk-in refrigerator that were not properly labeled or dated, including a pan of red beans, fried rice, roasted potato wedges, and tomato soup, all of which were past their discard dates or had illegible labels. Additionally, a pan of red liquid had an illegible label, and there were approximately a dozen orange juice containers that were sticky, wet, and included one open, leaking container. Three broken eggs were also found, with their contents covering the inside of a box containing several dozen whole, raw eggs. The Regional Food Service Director acknowledged that the observed food items should have been discarded after seven days and should have had legible labels with the contents and preparation dates. The Director also confirmed that the leaking orange juice container and broken eggs should have been discarded. The facility Administrator acknowledged the findings in the main kitchen during a subsequent interview. These observations and acknowledgments indicate a failure to adhere to the 2022 FDA Food Code requirements for package integrity and date marking of ready-to-eat, time/temperature control for safety foods.
Failure to Follow Physician Orders for Medication and Wound Care
Penalty
Summary
The facility failed to ensure that nursing services were provided in accordance with professional standards of quality by not following physician's orders for a resident with hypotension. The resident had a physician's order for Midodrine 5 mg to be administered three times daily as needed for low blood pressure, specifically when systolic was less than 100 or diastolic less than 60, and for vital signs to be taken every shift for seven days. Despite multiple documented instances where the resident's blood pressure readings met the criteria for administration of Midodrine, there was no evidence in the Medication Administration Record that the medication was given as ordered. Both a registered nurse and the Director of Nursing Services confirmed that the medication was not administered when indicated. Additionally, the facility did not follow a physician's order for wound care for the same resident. The order specified cleansing the left posterior calf with normal saline, patting dry, applying calcium alginate, and covering with bordered gauze every evening shift. On one evening shift, the wound treatment was not completed, and the nurse documented that the resident was sleeping. The Director of Nursing Services was unable to provide evidence that the wound care was performed as ordered on that date.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
A resident with a history of atrial fibrillation and hypotension was admitted to the facility and prescribed Metoprolol Tartrate, with specific parameters to hold the medication if the systolic blood pressure was less than 100. Upon admission, the resident's blood pressure readings were consistently low, with the highest being 78/48. Despite these low readings, the medication was administered on multiple occasions, as documented in the Medication Administration Record (MAR). The original physician's order included parameters to hold Metoprolol for low systolic blood pressure, but after a revision to the administration times by a registered nurse, these parameters were no longer visible in the order. Staff interviews confirmed that the medication was given even when the resident's blood pressure was below the specified threshold, and staff were unaware that the parameters had been removed from the order. This resulted in the resident receiving unnecessary medication contrary to the original physician's instructions.
Failure to Ensure Resident Free from Significant Medication Errors with Warfarin Administration
Penalty
Summary
A resident with a diagnosis of deep vein thrombosis was admitted to the facility and prescribed Warfarin to treat and prevent blood clots. The physician ordered a PT/INR test to be performed, which was completed as scheduled. However, there was no evidence that the PT/INR results were reviewed or that the provider was notified of the results. Additionally, there was no documentation of a new Warfarin order for continued therapy following the test. As a result, the resident did not receive Warfarin doses on two consecutive days. Further review showed that a Coumadin Alert order, intended to ensure staff awareness and proper administration of Warfarin, was not transcribed until several days after the missed doses. Staff interviews confirmed the lack of documentation regarding the PT/INR results and the absence of a Warfarin order during the period in question. The Director of Nursing acknowledged the delay in transcribing the Coumadin Alert and confirmed the missed medication doses.
Failure to Honor Resident Dignity and Electronic Monitoring Rights
Penalty
Summary
A deficiency was identified when a nursing assistant (NA) failed to treat a resident with respect and dignity during care. The NA was observed and acknowledged making a comment about the resident's odor within earshot of the resident, who was able to understand and respond to yes/no questions. This action was captured on video surveillance footage provided by the resident's family. The facility's policies require that all residents be treated with respect and dignity, and the Director of Nursing Services (DNS) was unable to provide evidence that the resident was treated appropriately in this instance. Additionally, the same NA was observed on video covering the resident's electronic monitoring camera with a pillow, despite the resident having provided consent for video surveillance and appropriate signage being posted in the room. The DNS confirmed that the NA covered the camera and could not provide evidence that the resident's right to use electronic monitoring equipment was respected. The resident involved had diagnoses including altered mental status and seizures and had been admitted to the facility several months prior to the incident.
Failure to Follow Enhanced Barrier Precautions for Resident with Gastrostomy
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically regarding the use of Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy. Facility policy mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices or wounds. Despite signage indicating EBP requirements in the resident's room, video surveillance footage on two separate dates showed that two nursing assistants provided morning care to the resident without wearing gowns, as required by policy. Interviews with the Infection Preventionist and the nursing assistants confirmed that the resident had been on EBP since admission and that staff were aware of the requirement to wear gowns and gloves during care. However, both nursing assistants acknowledged not wearing gowns during the observed care episodes. The Director of Nursing Services was unable to provide evidence that the facility maintained an infection control program to prevent the spread of infection related to EBP for this resident.
Failure to Implement Surgical Wound Care Orders Upon Admission
Penalty
Summary
A deficiency occurred when a resident admitted with a diagnosis including sepsis due to Serratia did not receive surgical wound care as directed in the hospital's continuity of care document. The discharge instructions specified that the resident's left hip incision site should be cleansed with Vashe cleanser, patted dry, and covered with an antibacterial dressing and protective cover daily and as needed. Although these instructions were provided to the facility upon admission, there was no evidence that a physician's order for the wound treatment was implemented until three days after admission. Staff interviews confirmed that the surgical wound care instructions were present in the admission documentation but were not acted upon until several days later. The Unit Manager acknowledged the delay, and the Nurse Practitioner stated that the treatment order should have been implemented upon admission. The DON was unable to provide evidence that the wound care order was carried out as required during the initial days following the resident's admission.
Failure to Ensure Nursing Staff Competency During Emergency Transfer
Penalty
Summary
Licensed nursing staff failed to demonstrate the necessary competencies and skills to meet resident needs during an emergency transfer. Specifically, an LPN incorrectly identified a resident experiencing a significant change in condition and reported the wrong resident to the on-call provider. The LPN also sent the incorrect medical record and patient identifiers with the resident during transfer to the hospital, resulting in the hospital treating the resident under another individual's information for approximately two hours. The facility's policy required nursing staff to collect and organize pertinent information and accurately report the resident's current symptoms and status to the physician, which was not followed in this instance. The resident involved had a history of chronic obstructive pulmonary disease and congestive heart failure and was admitted to the hospital's Intensive Care Unit requiring intubation after presenting with altered mental status, excessive sputum, and cool skin. The LPN did not provide a verbal report to the hospital at the time of transfer, and the Director of Nursing Services was unable to provide evidence that the LPN was competent with the facility's protocol for acute condition changes. This series of actions and omissions resulted in the resident being at risk for delayed or inappropriate treatment.
Failure to Provide Accurate Resident Identification During Emergency Transfer
Penalty
Summary
The facility failed to ensure accurate and appropriate information was communicated to the receiving health care provider during an emergent discharge. When a resident experienced a significant change in condition requiring emergency transfer to an acute care facility, an LPN incorrectly identified the resident and sent the individual to the hospital with another resident's identifiers and medical record. As a result, the resident was registered at the hospital under the wrong name and date of birth, and medical care was provided under the incorrect identity for approximately two hours. The error was discovered when the hospital contacted the facility to clarify the resident's identity. Record review showed that the resident who was actually transferred had a history of chronic obstructive pulmonary disease and congestive heart failure and was in severe respiratory distress at the time of transfer, requiring intubation. The incorrect medical record and identifiers were provided to EMS, and the resident was unable to correct the information due to decreased consciousness. The Director of Nursing Services confirmed that the wrong medical record was sent and acknowledged the resident's history of respiratory compromise. The incident resulted in the resident's representative not being contacted for consent for intubation, as the hospital had contacted the wrong representative based on the incorrect identifiers.
Failure to Implement Consistent, Comprehensive Care Plans for Safe Transfers
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for two residents with identified needs for safe transferring and fall prevention. For one resident with type II diabetes and chronic kidney disease, there were multiple conflicting interventions documented regarding transfer assistance, including discrepancies between the care plan, Kardex, physician orders, Safe Patient Handling (SPH) evaluations, and nursing assistant (NA) assignments. These inconsistencies ranged from requiring a mechanical lift with two staff, to a stand and pivot transfer with a gait belt, to a one-person assist, with no evidence of consistent communication or documentation to ensure safe transfers. Staff interviews confirmed the lack of alignment and clarity in transfer instructions across different documentation sources. For another resident with type II diabetes and muscle weakness, similar inconsistencies were found. The care plan, Kardex, physician orders, SPH evaluation, and NA assignments all contained differing information regarding the resident's transfer and ambulation needs, ranging from supervision with a walker to requiring a mechanical lift with two staff. Staff interviews acknowledged that the SPH status was not consistently reflected across all forms of communication and documentation, and that the information should be uniform to ensure safe care. These findings were based on record reviews, staff interviews, and a community complaint alleging frequent patient falls and safety risks.
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