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)
Some of the Latest Corrective Actions taken by Facilities in Rhode Island
Latest Citations in Rhode Island
A resident with a history of anxiety and mood disorders experienced a significant medication error when clonazepam was abruptly discontinued for several days during a gradual dose reduction process. The resident did not receive the medication as ordered, leading to increased anxiety and hand tremors. Facility staff and providers failed to ensure proper communication and follow-up regarding the medication changes, resulting in the resident not being free from significant medication errors.
A resident with recent spinal surgery did not receive prescribed pain medications as ordered. The Buprenorphine patch was not available and was falsely documented as administered, while Dilaudid was given at half the prescribed dose on two occasions. Staff interviews and record reviews confirmed these discrepancies, and the DON acknowledged the failure to follow physician orders.
A resident with dementia and anxiety disorder, who was cognitively intact, threatened to physically harm another resident and was sent to the ER for evaluation. The DON acknowledged that this incident, which met the criteria for abuse reporting, was not reported to RIDOH as required by state law and facility policy.
Surveyors found that medications, including Trelegy Ellipta inhalers, Morphine Sulfate, and Lorazepam Intensol, were opened and not dated, and that Lorazepam was not refrigerated as required. Staff acknowledged these lapses in medication storage and labeling during interviews.
Three residents with conditions such as hemiplegia, Alzheimer's disease, and cognitive impairment did not receive timely bowel interventions or GI assessments as required by facility protocol when experiencing multiple days without adequate bowel movements. Prescribed medications and interventions were not consistently administered, and providers were not notified of refusals or lack of results, as confirmed by staff interviews.
A resident who required two-person assistance for transfers sustained fractured ribs after a nursing assistant attempted to pull the resident backwards in a shower chair up a steep incline into a shower stall. The chair tipped and broke, causing the resident to fall and require hospital admission. The incident occurred despite manufacturer warnings against using the chair on an incline and the resident's care plan specifying the need for two staff during transfers.
Nursing staff administered a controlled medication prescribed for one resident to another hospice resident due to a pharmacy backorder, in violation of facility policy. The transfer and administration of the medication were inaccurately documented in the narcotic count book, and the physician's order was entered with the incorrect route. Staff acknowledged the errors in both medication handling and documentation.
Two residents with complex medical conditions did not have required weekly skin assessments documented, despite physician orders and MAR sign-offs indicating completion. The DON was unable to provide evidence that these assessments were performed or recorded as required.
A resident admitted after spinal surgery with a Hemovac drain and surgical wound did not have a baseline care plan developed within 48 hours that addressed care instructions for the wound or drain. Nursing leadership confirmed the omission when interviewed, and the resident was later hospitalized after presenting with signs of infection.
A resident with a Hemovac drain following spinal surgery did not have their drain output monitored or documented as required by facility policy. There were no physician orders for drain management, and staff could not provide evidence of required monitoring or documentation. This failure was confirmed by interviews with nursing staff, the DON, and the facility physician, as well as by the lack of documentation provided to the surgeon's office.
Abrupt Discontinuation of Clonazepam Results in Significant Medication Error
Penalty
Summary
A deficiency occurred when a resident with a history of bipolar disorder and major depressive disorder, who had been receiving clonazepam for anxiety, did not receive the medication for several days due to abrupt discontinuation. The resident's medication orders were changed multiple times as part of a gradual dose reduction (GDR) plan, but after the last order was discontinued, there was a gap from the evening of 5/16/2025 through 5/19/2025 during which the resident did not receive any clonazepam. The resident reported increased anxiety and worsening hand tremors during this period. Interviews with facility staff and medical providers revealed a lack of clear communication and follow-up regarding the GDR plan and the resident's medication needs. The psychiatric provider who initiated the GDR was no longer assigned to the resident and did not reassess the resident after the dose reduction. The medical director was not notified of the missed doses until several days later, at which point a new order for a lower dose was provided. The facility was unable to provide evidence that the resident remained free from significant medication errors, as the abrupt discontinuation of clonazepam occurred without appropriate oversight or a proper GDR process.
Failure to Administer Pain Medications per Physician Orders
Penalty
Summary
A deficiency was identified when a resident, recently readmitted with diagnoses including spinal fusion and orthopedic aftercare, did not receive prescribed pain management medications according to physician orders. The resident was ordered to receive a Buprenorphine patch on a specific date, but the medication was not available in the facility at the time, and a nurse signed off on the administration despite it not being given. This was confirmed through staff interviews and record reviews, which showed the patch was not applied as ordered. Additionally, the same resident was prescribed Dilaudid 4 mg by mouth every six hours as needed for pain, but records revealed that only 2 mg doses were administered on two occasions, contrary to the physician's order. Staff interviews confirmed that the lower dose was given, and the Medication Administration Record inaccurately reflected the administration of the full prescribed dose. The Director of Nursing acknowledged that the resident did not receive the medications as ordered.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the Rhode Island Department of Health (RIDOH) as required by state law and facility policy. Specifically, a resident with diagnoses including dementia and anxiety disorder, who was cognitively intact according to a recent assessment, threatened to physically harm another resident. This incident was documented in a progress note, and the resident was subsequently sent to the emergency room for evaluation and admitted. Despite the facility's policy requiring immediate reporting of suspected abuse to the Director of Nursing and RIDOH, the Director of Nursing acknowledged during a surveyor interview that the incident was not reported to RIDOH. The failure to report the allegation of abuse in a timely manner constituted noncompliance with both state regulations and the facility's own procedures.
Failure to Properly Store and Label Medications
Penalty
Summary
Surveyor observations revealed that drugs and biologicals were not stored and labeled according to professional standards in two of four medication carts inspected. Specifically, two Trelegy Ellipta inhalers were found opened and undated, despite manufacturer instructions requiring disposal six weeks after opening. Additionally, Morphine Sulfate and Lorazepam Intensol oral suspension were found opened and undated, with the Lorazepam not stored in the required refrigerated conditions. The pharmacy label and manufacturer instructions for these medications specify discard dates and storage requirements that were not followed. Staff present during these observations, including a Certified Medication Technician, an LPN, and an RN, acknowledged the deficiencies when interviewed by surveyors. The Director of Nursing Services also confirmed that medications should be dated when opened and that Lorazepam should be refrigerated. These findings were consistent with a community complaint alleging improper medication storage and administration.
Failure to Follow Bowel Protocol and Provide Timely Interventions for Constipation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents experiencing constipation. For one resident with right-sided hemiplegia and bowel incontinence, documentation showed gaps of four days without a bowel movement on two occasions, with no evidence that bowel interventions, GI assessments, or physician notifications were completed as required by the facility's bowel protocol. Another resident with Alzheimer's disease and bowel incontinence went five days without a documented bowel movement, and records did not show that interventions were administered per protocol, nor that a GI assessment or provider notification occurred after failed or refused interventions. A third resident, with mild cognitive impairment and a urinary system malignancy, had only one small bowel movement over four days and did not receive prescribed Polyethylene Glycol or required interventions per the bowel protocol. There was no documentation of GI assessments or provider notifications for this resident either. Staff interviews confirmed that the bowel protocol was not followed and that adequate bowel movements were not documented for these residents during the identified periods.
Resident Injury Due to Improper Use of Shower Chair on Incline
Penalty
Summary
A resident with a history of falls and fractures, who was dependent on staff for showers and required assistance from two staff members for transfers, sustained a fall with injury during a shower. The incident occurred when a nursing assistant attempted to pull the resident, seated in a shower chair, backwards up a pronounced incline into the shower stall. As the chair was pulled over the incline, the front wheels lifted off the ground, causing the chair to tip backwards. The staff member was unable to stabilize the resident due to the resident's weight, resulting in the resident being lowered to the ground as the back of the chair broke. The resident subsequently complained of pain and was found to have fractured ribs, requiring admission to the Trauma Intensive Care Unit. Surveyor observation confirmed that the entrance to the shower stall had a steep incline, and review of the shower chair manufacturer's manual indicated that the equipment should not be used on an incline and all casters should remain in contact with the floor. Staff interviews revealed that only one staff member was present during the transfer into the shower stall, despite the resident's care plan requiring two-person assistance. The facility's investigation and staff statements corroborated that improper use of the shower chair and inadequate supervision contributed to the accident, resulting in significant injury to the resident.
Failure to Adhere to Medication Administration Standards and Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by administering medication prescribed for one resident to another and inaccurately documenting the transfer and administration of a controlled substance. Specifically, a resident on hospice care with a diagnosis of malignant neoplasm of the bronchus and secondary malignant neoplasm of the digestive organs was ordered Lorazepam Intensol for restlessness and anxiety. Due to a pharmacy backorder, nursing staff borrowed an unused bottle of Lorazepam Intensol prescribed for another resident and administered it to the hospice resident. Documentation in the narcotic count book was inaccurate, as 15 ml was recorded as transferred when in fact 30 ml was moved, and there was no clear evidence of the medication being properly transferred or received from the pharmacy. Facility policy explicitly prohibits administering medications supplied for one resident to another. The medication administration record confirmed that the hospice resident received doses from the borrowed medication on multiple occasions. Staff interviews revealed acknowledgment of the errors, including the incorrect route of administration entered in the physician's order and the improper borrowing and documentation of the medication. The staff educator confirmed that the medication should not have been borrowed and that the narcotic documentation was incomplete and inaccurate.
Failure to Document and Complete Physician-Ordered Skin Assessments
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that weekly skin assessments ordered by physicians were completed and documented for two residents. For one resident admitted with altered mental status and a history of falls, a physician's order required weekly skin evaluations with documentation under observations. Although the Medication Administration Record (MAR) indicated that the assessment was completed, there was no evidence in the weekly skin evaluation observations or progress notes to confirm that the assessment was actually performed on the specified date. Similarly, another resident admitted with Parkinson's Disease, dementia, and a nasal bone fracture had a physician's order for weekly skin evaluations. The MAR showed that these assessments were signed off as completed on two occasions, but a review of the weekly skin evaluation observations and progress notes did not provide evidence that the assessments were conducted or documented as required. During an interview, the Director of Nursing Services was unable to provide documentation to support that the assessments had been completed per the physician's orders.
Failure to Develop Baseline Care Plan for Surgical Wound and Hemovac Drain
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted following spinal fusion surgery and required orthopedic aftercare. Upon admission, documentation indicated the presence of a surgical dressing on the posterior back and a Hemovac drain with serosanguineous drainage. However, review of the baseline care plan revealed no evidence of care planning related to the surgical wound or the Hemovac drain, including necessary treatments or interventions. A complaint submitted to the state health department indicated that the resident was later found to be not alert, babbling, lethargic, and altered during a post-operative visit, with lab results showing elevated white blood cells. The resident was subsequently sent to the emergency room and admitted to the hospital for further care. During interviews, facility nursing leadership acknowledged the omission of instructions in the baseline care plan regarding the surgical wound and Hemovac drain.
Failure to Monitor and Document Hemovac Drain Output per Professional Standards
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in the care of a resident with a Hemovac drain following spinal surgery. Upon admission, documentation noted the presence of a surgical dressing and Hemovac drain with serosanguineous drainage, but there was no evidence that the output from the drain was measured or recorded according to facility policy, which requires emptying and measuring every 4 to 8 hours. Review of the resident's medical record revealed a lack of physician orders for monitoring, emptying, or documenting the Hemovac drain's function and output during the resident's stay. Staff interviews confirmed that there was no documentation or recollection of orders related to the drain, and the Assistant Director of Nursing and Director of Nursing were unable to provide evidence of required monitoring or orders for the drain during the relevant period. Further, during a follow-up appointment, the facility was unable to provide documentation of the Hemovac drain's output to the surgeon's physician assistant, who expected at least twice-daily monitoring and documentation. The facility physician also stated that standard practice includes having orders to monitor drainage, ensure proper function, and observe for infection. The lack of documentation and physician orders for the Hemovac drain's management, as well as the absence of output monitoring, constituted a failure to meet professional standards of quality for this resident.