State Hospital Cited for Failing to Provide Proper Care to 72% of Patients Sampled
Sunday, November 24, 2019
A state hospital in Rhode Island was recently cited for failing to provide proper care to 72% of patients sampled in a recent survey.
State and federal surveys of the Zambarano Unit of the state-run Eleanor Slater Hospital in Burrillville also found that patients' rights were not met, following complaints made to the Rhode Island Department of Health.
Investigations were conducted from September 18 through October 3 by federal and state authorities at Zambarano, which cares for, on average, 90 to 93 individuals living with developmental disabilities and co-occurring medical conditions.
GET THE LATEST BREAKING NEWS HERE -- SIGN UP FOR GOLOCAL FREE DAILY EBLASTThe federal report outlines the case of a patient who fell in the shower with a possible hip fracture-- and that regulators found that routine 30-minute checks had not been conducted.
SLIDES: Read the Federal and State Surveys HERE
According to the federal report:
Based on record review and staff interviews, it has been determined that the hospital failed to meet the Nursing Services Condition of Participation relative to failure to follow their policy for safe and supportive observation for patients for 13 of 18 sample patients who were not observed according to their prescribed level of observation.
The facility has failed to provided nursing care for each patient in accordance to the [Licensed Independent Practitioner] orders for 5-minute close or 30-minute routine observation.
The report also noted "failure to follow their policy for 2 of 2 sample patients who were administered medications via a G-Tube at the Zambarano Unit" and "failure to follow their policy for hyperthermia/hypothermia machines for 3 of 3 sample patients who had physicians orders for hyper-hypothermia machines."
Zambarano was allowed to provide a plan of correction for the deficiencies.
"The failure on the part of the staff to follow the Safe and Supportive Observation of Patients Policy has been addressed," wrote the hospital. "All LIPS have been educated in policy and procedure. Orders to reflect observation status and documentation was reviewed (11/13/19)."
Some of the corrective actions on the forms were dated before the investigation took place -- which the Department of Health said was an "error."
"Where it states 8/23, it should have been 11/23," said Joseph Wendelken with the Rhode Island Department of Health.
State History -- and State Findings
In the late 1800s, Rhode Island opened two hospitals – the State Hospital for Mental Disease and the State General Hospital— in what is now known as the Pastore Complex in Cranston.
In 1905, the Rhode Island State Sanatorium opened in Burrillville to treat tuberculosis patients. The General Hospital and State Hospital for Mental Disease merged to become the Rhode Island Medical Center in 1962, with the name change to the Eleanor Slater Hospital taking place in 1994.
Today, the Eleanor Slater Hospital System is still located on two campuses, Cranston and Burrillville. It is the state’s only Long Term Acute Care Hospital (LTACH) with 284 beds and operated through the State of Rhode Island’s Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH). The hospital provides long-term acute and post-acute hospital level of care to patients with complex medical and psychiatric needs.
The recent state survey found that the requirement that the “governing body shall ensure that there is an effective, ongoing, hospital-wide quality improvement program to evaluate the provision of patient care” at Zambarano was not met.
The state also found that the requirement that “all parts of the hospital and its premises shall be kept clean, neat, free of litter and rubbish, and all furnishings” was not met.
A state surveyor found in one shower room that the “shower was not clean, had large amounts of black matter on the bottom, sides, and around the shower faucet. Additionally, there were multiple cracked tiles and missing grout.”
Surveyors the next day found the same condition, despite the nurse manager the day before “acknowledging the showered needed to be cleaned.”
During an interview on the second day, the housekeeping supervisor “was unable to produce evidence of when the shower was last cleaned.”
"The Plan of Correction developed by hospital administrators was accepted by RIDOH because it lays out clear steps that have been taken, or that will be taken, to ensure that the issues identified are being addressed. RIDOH surveyors will be back at the hospital in the near future for an unannounced site visit to ensure that the plan is being followed," said Joseph Wendelken with the Rhode Island Department of Health, who noted such a visit would be "protocol."
"However, to this point, hospital administrators have been very responsive and very proactive in addressing each of RIDOH’s surveyors’ findings," he added.
This article was first published 11/23/19 2:30 AM
