Inspection Reports for Pawtucket Falls Healthcare Center

The complaint involved a verbal altercation between Resident ID #2 and a nursing assistant (Staff A) during care of the resident's roommate. The resident reported feeling physically threatened. The facility substantiated the allegation, suspended and disciplined Staff A, and re-educated her. The social worker did not document or follow up with the resident as expected.

The facility failed to provide medically-related social services to maintain the highest practicable well-being for Resident ID #2. The investigation substantiated the staff to resident altercation, resulting in suspension, re-education, and discipline of the involved staff member. The social worker was aware of the incident but did not document or follow up appropriately with the resident.

The survey was an off-hour recertification and complaint survey (ACTS reference number 93898) conducted to investigate allegations related to resident falls, treatment standards, and care practices. Findings included inaccurate assessments of a resident's fall injury and failure to meet professional standards in care.

Deficiencies were identified related to accuracy of assessments, professional standards of care, increase/prevent decrease in range of motion/mobility, dialysis care, and life safety code compliance including fire drills and electrical systems. The facility failed to accurately reflect a resident's fall injury in assessments, ensure orthostatic blood pressure monitoring, prevent contractures, monitor fluid restrictions, and maintain emergency power and fire safety systems.

The facility was found deficient in accurately documenting resident assessments, following physician orders for orthostatic blood pressure monitoring, applying prescribed devices to maintain range of motion, and monitoring fluid restrictions for residents requiring dialysis. Several residents' care plans and physician orders were not properly implemented or documented, leading to minimal harm or potential for harm.

The complaint investigation was triggered by community reports alleging incorrect urinary catheter placement, medication errors, lack of certified food protection managers, and COVID-19 positive staff working while infectious. The complaint was substantiated with findings of harm and immediate jeopardy.

The facility failed to ensure licensed nurses had competencies for urinary catheter insertion, resulting in incorrect catheter placement and resident harm. Medication administration errors were identified for one resident, including missed and extra doses. The facility lacked certified food protection managers during multiple meal shifts, with an uncertified staff member working as the sole cook. Infection control failures included allowing a COVID-19 positive staff member to work in the kitchen, leading to an outbreak among residents. Additionally, the facility failed to provide required training on abuse, infection control, dementia care, trauma informed care, and QAPI for multiple staff members.

The complaint reported to the Rhode Island Department of Health on 5/6/2024 alleged that Resident ID #2 was discharged to the hospital on 5/2/2024 without being provided a bed hold form, and the facility had already filled the resident's bed. The facility also failed to develop a baseline care plan for the resident within 48 hours of admission.

The facility failed to provide written notice of bed-hold policy to Resident ID #2 prior to hospital transfer on 5/2/2024 and did not develop a baseline care plan within 48 hours of admission that included necessary instructions for effective and person-centered care. The facility also declined to accept the resident back after hospital discharge despite having bed availability.

The complaint investigation found that CPR was initiated on Resident ID #1 despite the resident's documented DNR status on the MOLST forms and face sheet. The facility had two MOLST forms for the resident, one unsigned by a qualified medical professional. Interviews with the Medical Records Supervisor and Director of Nursing Service failed to explain these discrepancies or why CPR was started.

The facility failed to ensure that the resident's Advanced Directive to refuse lifesaving treatment was followed, resulting in CPR being initiated despite the resident's Do Not Resuscitate (DNR) status. The resident's medical record contained two conflicting Medical Orders for Life Sustaining Treatment (MOLST) forms, one unsigned by a qualified medical professional.

The facility was found deficient in multiple areas including failure to protect resident identifying information, incomplete care plan revisions for advanced directives, inadequate pressure ulcer care, improper catheter care, lack of physician orders for oxygen therapy, failure to conduct trauma-informed care assessments, improper medication administration and monitoring, and failure to properly label and store medications.

The visit was a complaint/incident investigation survey combined with recertification and emergency preparedness surveys. Deficiencies were cited as a result of the complaint investigation and survey findings.

Deficiencies were cited related to failure to protect identifying information of residents, failure to revise comprehensive care plans timely, failure to provide necessary treatment and services to prevent pressure ulcers, failure to provide appropriate bowel/bladder incontinence care and catheter care, failure to provide respiratory care consistent with professional standards, failure to provide trauma-informed care, failure to ensure drug regimen free from unnecessary drugs, failure to maintain fire alarm and sprinkler systems, failure to conduct fire drills properly, and failure to properly label and store drugs and biologics.

The complaint investigation revealed that Resident ID #1, a Level III Sex Offender admitted without prior screening, inappropriately touched Resident ID #2, a vulnerable resident with severe cognitive impairment, and a staff member. The facility failed to implement adequate supervision and safety measures after learning of Resident ID #1's sex offender status. The facility also failed to screen Resident ID #7 for sex offender status prior to admission.

The facility failed to keep a resident free from sexual abuse by another resident who was a Level III Sex Offender. The facility also failed to screen newly admitted residents for sex offender status prior to admission, resulting in inappropriate sexual contact with a vulnerable resident. Additionally, the facility failed to provide adequate supervision to prevent incidents by the known sex offender and failed to implement safety interventions after becoming aware of the resident's criminal history.

The complaint was substantiated based on record reviews and interviews confirming verbal abuse occurred between Resident ID #1 and Staff A.

The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving verbal abuse between Resident ID #1 and Staff A, confirmed through multiple staff and resident interviews.

The facility failed to ensure proper storage, preparation, distribution, and serving of food according to professional standards. Observations included opened bags of dry food not stored in closed containers, accumulation of frost and debris in the freezer, potentially hazardous foods left out during meal service, and coffee mugs with a brown film inside.

Complaint received on March 26, 2023, alleging unsafe discharge related to suitable housing and wound care. The complaint was substantiated by findings of incomplete discharge documentation and fabricated AMA discharge paperwork.

The facility failed to complete the discharge interagency documentation in its entirety, omitting necessary care details for the resident's wounds, treatments, medications, and referrals. The resident was discharged to a motel without evidence of a safe discharge process, and a fabricated AMA (Against Medical Advice) discharge document was discovered. Interviews confirmed the resident was not discharged AMA but routine, and the facility staff could not provide evidence of complete discharge coordination.

This visit was a follow-up to a complaint investigation. The complaint was substantiated as deficiencies were found and corrected during the follow-up survey.

The facility was found to have previously failed to ensure food was stored covered or tightly wrapped to prevent contamination. Immediate corrective actions were taken, including removal of uncovered food items, staff education, and implementation of audits to ensure compliance with food safety standards.

The complaint investigation found that the resident sustained a burn on 3/4/2023 during therapy after a staff member applied wet hot cloths. The burn was substantiated as actual harm with a first degree burn progressing to a partial thickness second degree burn requiring specialized wound care treatment.

The facility failed to ensure the resident's environment was free from accident hazards, resulting in a burn injury due to improper use of a hydrocollator hot pack, including failure to remove topical analgesics, inadequate toweling layers, and lack of pre/post skin assessments as required by policy.

The facility failed to store all drugs and biologicals in locked compartments as required, resulting in missing medication for one resident. Despite a thorough search and interviews, the medication was not recovered, and the facility's policy on medication storage was not followed.

The complaint investigation focused on allegations of inadequate feeding assistance, medication errors, failure to maintain nutritional status, improper use of bed rails, and inappropriate medication regimens.

The facility failed to provide one-on-one feeding assistance as ordered for Resident #9, failed to ensure medication administration per physician orders for Resident #3, failed to maintain acceptable nutritional status and follow weight monitoring policies for Resident #4, failed to assess bed rail safety risks for Resident #9, administered medications outside prescribed parameters for Resident #13, and failed to reevaluate antipsychotic medication orders for Resident #12.

The facility was found deficient in multiple areas including failure to convey resident funds upon death, inadequate communication during resident discharge, incomplete resident assessments, inaccurate skin assessments, insufficient assistance with activities of daily living, inadequate wound care, improper foot care, nutritional deficiencies, respiratory care issues, medication management errors, improper medication storage, failure to report critical lab results, food safety violations, and improper COVID-19 testing procedures.

The visit included a complaint/incident investigation with reference numbers 82328, 81890, 82435, and 82413. The facility was found not in compliance with advance directives and other care standards as a result of the complaint investigation.

The facility was found not in compliance with requirements related to advance directives, comprehensive care plans, nutrition and hydration, respiratory care, nursing services, medication management, food safety, resident records, and life safety code deficiencies. Corrective actions and plans of correction were provided for multiple deficiencies.