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 nursing assistant did not receive required Abuse Prohibition training upon hire, as revealed during an investigation into an alleged staff-to-resident abuse incident involving a resident with multiple sclerosis and rheumatoid arthritis who was cognitively intact. The DON confirmed that there was no documentation of the mandated training for the staff member.
Two residents with complex care needs did not have comprehensive, person-centered care plans in place. One resident who suffered a fall with injury and required hospitalization did not have this event addressed in their care plan. Another resident with multiple mobility issues had conflicting instructions in their care plan regarding transfer devices, with no clear specification of the appropriate method. The DON was unable to provide documentation of accurate, individualized care plans for these residents.
A resident did not receive the specialized rehabilitative services required for their care, as the facility failed to provide or arrange for these necessary interventions according to the resident's care plan.
Nursing staff failed to demonstrate proper infection control practices for a resident requiring contact precautions due to an ESBL infection. Multiple staff members entered the resident's room without performing hand hygiene or using required PPE, and interviews revealed a lack of understanding about contact precaution protocols, despite having completed infection control competencies.
A resident with ESBL in the urine had a physician's order for contact precautions, but a nursing assistant repeatedly entered the room without performing hand hygiene or donning required PPE, despite posted signage. The staff member was unaware of the precautions, and leadership confirmed the expectation for proper infection control measures.
A nursing home area was found to have accident hazards and lacked adequate supervision, resulting in a deficiency for not preventing accidents as required.
A medication technician administered Donepezil, Namenda, Senna, and Plavix to a resident who did not have physician orders for these drugs, due to confusion between two roommates. The error was discovered after a nurse realized the medications were given to the wrong individual, and the DON confirmed the administration of unnecessary medications.
A resident with dementia and mobility issues experienced an unwitnessed fall and showed signs of a possible hip fracture. Although a STAT right hip X-ray was ordered, the facility did not obtain the X-ray within the expected timeframe, and staff did not notify the provider of the delay. The resident's condition worsened, leading to hospitalization where a hip fracture was confirmed. Staff interviews confirmed expectations for timely STAT X-rays and provider notification in case of delays, and the DON acknowledged ongoing issues with radiology service timeliness.
A resident with COPD and a physician's order for oxygen therapy was found on multiple occasions with an empty portable oxygen cylinder and no documented monitoring of oxygen supply. The resident experienced critically low oxygen saturation levels, and staff failed to utilize available oxygen concentrators or adequately monitor the oxygen delivery, resulting in periods of hypoxia.
Surveyors found that food items in the main kitchen and two kitchenettes were not properly labeled or dated, as required by state food code and facility policy. Additional issues included a dusty kitchen fan blowing towards food being prepared and a dietary aide not fully covering his hair with a hair net. The Food Service Director acknowledged these failures during interviews.
Failure to Ensure Abuse Prevention Training for Nursing Assistant
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide care that assures resident safety and maximizes well-being, as required by resident assessments and individual care plans. Specifically, a review of records and staff interviews revealed that a nursing assistant, Staff A, did not complete the required Abuse Prohibition training upon hire, as mandated by facility policy. This deficiency was identified during the investigation of an alleged staff-to-resident abuse incident involving Staff A and a resident with multiple sclerosis and rheumatoid arthritis, who was cognitively intact at the time of the incident. Further review showed that the facility's Abuse Prohibition Policy requires all employees to receive training on abuse prevention during orientation and at least annually. However, there was no documentation that Staff A had received this training upon hire or after the abuse allegation was reported. The Director of Nursing Services confirmed the absence of training records for Staff A and acknowledged that additional abuse prevention training would have been expected following the incident.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant care needs. For one resident who was re-admitted with a history of a displaced intertrochanteric fracture of the left femur, documentation showed that the resident experienced a fall resulting in a hip fracture and required hospitalization and surgery. However, review of the resident's care plan did not show any evidence that the actual fall with injury was addressed or incorporated into the care plan, and the Director of Nursing Services was unable to provide documentation of a comprehensive care plan related to this incident. For another resident with diagnoses including a left patella fracture, hip pain, and dementia, the care plan contained conflicting instructions regarding transfer methods. The plan indicated the use of a mechanical lift requiring two staff for transfers, but also referenced the use of a slide board for transfers. Further documentation confirmed the resident was dependent for all transfers, yet the care plan did not specify a single, consistent transfer device. The Director of Nursing Services acknowledged the inconsistency and was unable to provide evidence of a comprehensive, person-centered care plan that accurately reflected the resident's transfer needs.
Failure to Provide Required Specialized Rehabilitative Services
Penalty
Summary
A resident did not receive specialized rehabilitative services as required for their care. The facility failed to provide or obtain these services, which are necessary to meet the resident's assessed needs. This inaction resulted in the resident not receiving the appropriate rehabilitative interventions as indicated in their care plan.
Failure to Ensure Staff Competency in Infection Control and Contact Precautions
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to prevent the transmission of communicable diseases and infections, specifically regarding contact precautions for a resident with an ESBL infection in the urine. Surveyor observations revealed that a nursing assistant entered the resident's room multiple times without performing hand hygiene or donning required personal protective equipment (PPE) such as gowns and gloves, despite clear signage indicating the need for contact precautions. The nursing assistant also entered another resident's room without performing hand hygiene in between. During interviews, the nursing assistant stated she was unaware of the contact precautions and misunderstood the requirements, believing PPE was only necessary when directly touching the resident. Further interviews with a certified medication technician and an LPN revealed similar gaps in knowledge, with both staff members unable to correctly describe when PPE should be used for residents on contact precautions. The Assistant Director of Nursing Services and Infection Preventionist confirmed that these staff members had completed infection control competencies but could not provide evidence that they demonstrated the necessary knowledge or skills for caring for residents on contact precautions. The deficiency was identified for three out of four nursing staff interviewed regarding contact precautions.
Failure to Follow Contact Precautions for Resident with ESBL
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required for residents with communicable diseases. Specifically, a resident with a diagnosis of ESBL in the urine had a physician's order for contact precautions, which included the use of gowns and gloves upon entering the resident's room. Surveyor observations revealed that a nursing assistant entered the resident's room on multiple occasions without performing hand hygiene and without donning the required gown and gloves, despite clear signage on the door indicating the need for contact precautions. The nursing assistant also entered another resident's room and then reentered the room of the resident on contact precautions, again without following proper infection control procedures. Interviews with the nursing assistant revealed a lack of awareness regarding the resident's contact precautions order and a misunderstanding of when to use personal protective equipment (PPE). The assistant director of nursing and the infection preventionist confirmed that the resident was actively being treated for ESBL and that staff were expected to perform hand hygiene and wear gowns and gloves upon entering the room. The failure to adhere to established infection control protocols was directly observed and acknowledged by staff during the survey.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and there was insufficient oversight to protect residents from potential accidents. This lack of proper supervision and the presence of hazards in the area directly contributed to the deficiency cited by surveyors.
Medication Administration Error Resulting in Unnecessary Drug Administration
Penalty
Summary
A deficiency occurred when a medication technician administered medications to a resident that were prescribed for the resident's roommate. The medications given in error included Donepezil, Namenda, Senna, and Plavix, none of which were ordered for the resident who received them. The resident who received the medications had a history of chronic kidney disease stage 3, anemia, essential hypertension, and unspecified dementia with anxiety, and was noted to have severe cognitive impairment based on a recent assessment. Review of the medication administration records confirmed that these medications were not prescribed for the resident who received them, but were instead prescribed for the roommate. The incident was discovered after a registered nurse realized that the medications intended for the resident in the bed by the window were instead given to the resident in the bed by the door. The nurse had handed the medication cup to the technician with instructions, but the technician administered the medications to the wrong resident. The Director of Nursing acknowledged that the resident had received unnecessary medications as a result of this error.
Failure to Obtain Timely STAT X-ray Following Resident Fall
Penalty
Summary
The facility failed to provide or obtain timely radiology services for a resident who sustained an unwitnessed fall and exhibited symptoms suggestive of a hip fracture, including right groin pain and a leg length discrepancy. A STAT right hip X-ray was ordered by the provider, and the resident was placed on bed rest pending results. Despite the STAT order, the X-ray was not performed within the expected timeframe, and the contracted radiology company did not provide a technician promptly. Nursing staff communicated with the resident about the pending X-ray and contacted the radiology company, but the X-ray was still not completed. Over the following day, the resident developed additional symptoms, including malaise, fever, and hypoxia, and experienced significant pain during care. The provider was updated about the resident's deteriorating condition, and the resident was eventually sent to the hospital, where a hip fracture was confirmed. Interviews with staff revealed that a STAT X-ray should be performed within four hours and that the provider should be notified if there are delays. The DON acknowledged that staff did not notify the provider of the delay in obtaining the X-ray, resulting in prolonged pain and hospitalization, and also stated that timeliness of X-ray services had been an ongoing issue with the contracted company.
Failure to Provide Safe and Consistent Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of non-ST elevation myocardial infarction and chronic obstructive pulmonary disease (COPD) was not provided with safe and appropriate respiratory care as required by professional standards. The resident had a physician's order for oxygen at 2 liters per minute via nasal cannula as needed. On two separate occasions, surveyor observations revealed that the resident's portable oxygen cylinder was empty, and there was no evidence in the medication and treatment administration records that the resident's oxygen supply was being monitored to ensure continuous delivery as ordered. During these times, the resident's oxygen saturation levels were found to be critically low, registering at 78% and later fluctuating between 85% to 86%, both well below the normal range. Staff interviews indicated a lack of awareness regarding the duration of oxygen cylinder supply and a failure to utilize available oxygen concentrators in the facility. The resident had been using portable oxygen cylinders exclusively, despite the availability of functional oxygen concentrators, and staff did not monitor the oxygen supply frequently enough to prevent depletion. The Director of Nursing Services confirmed that the resident should have been using an oxygen concentrator in the room and a portable cylinder only when out of the room, and that staff were expected to monitor the resident more closely when using portable oxygen. These failures resulted in the resident experiencing periods of hypoxia due to an empty oxygen supply.
Food Storage, Sanitation, and Staff Hygiene Deficiencies Identified
Penalty
Summary
Surveyor observations and staff interviews revealed that the facility failed to store and distribute food in accordance with professional standards and the Rhode Island Food Code. Specifically, multiple food items in the main kitchen's walk-in refrigerator, such as opened butter, bowls of pudding, plates and bowls of lemon meringue pie, opened cheese, sliced tomatoes, cut lettuce, and ricotta cheese, were found without proper labeling or dating. Similar deficiencies were observed in the second- and third-floor kitchenettes, where resident food containers and other items were not labeled or dated as required by facility policy. Additionally, an opened butter was found stored in a biohazard bag in one kitchenette. The Food Service Director acknowledged these failures during interviews. Further deficiencies included a kitchen fan with visible dust accumulation blowing towards food being prepared, which was confirmed by the Food Service Director. Additionally, a dietary aide was observed not wearing a hair net that fully covered his hair while working, in violation of the food code's requirements for hair restraints. These findings collectively demonstrate a lack of adherence to food safety and sanitation standards in the facility's food service operations.
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