Report: Lapses at state hospital reached 'level of immediate jeopardy' last month

PROVIDENCE — In early December, a federal agency determined that the "deficiencies" in nursing services at the state-run Eleanor Slater Hospital had reached "the level of immediate jeopardy," according to a previously undisclosed letter.

"These deficiencies have been determined to be of such a character to substantially limit the hospital's capacity to furnish adequate care and/or to adversely affect the health and safety of patients," a manager in the Northeast arm of the Centers for Medicare and Medicaid Services wrote the head of the state agency that runs the hospital on Jan. 14.

The letter, obtained by The Journal on Tuesday, indicates the "immediate jeopardy" was resolved. It is not clear how.

But that was only one in a lengthy series of CMS findings about lapses that enabled one psychiatric patient to overdose on a cupful of stockpiled pills; after-the-fact staff attempts to document patient safety checks without evidence they had occurred; an incorrectly recorded end-of-life directive.

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CMS findings at Eleanor Slater hospital

Among the findings, according to documents obtained by The Journal:

• "The hospital failed to complete the required observation/safety checks for 17 patients."

• "The hospital failed to provide the necessary supervision to maintain safety."

• "The hospital failed to prevent the inappropriate use of a restraint imposed as a means of retaliation by staff ... [and] monitor patients placed in restraint devices to ensure their physical and psychological needs were met."

Even more basically, "the hospital failed to demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for the prevention of transmission of the SARS-CoV-2, 2019 Novel Coronavirus as evidenced by failure to complete COVID-19 screening protocols upon entry to 2 of 4 hospital buildings."

Even more basically, the federal agency found no evidence the hospital's "governing body" met on any regular basis or that the hospital was what it said it was.

Bottom line: the letter informed Richard Charest, the director of the state's Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, that Eleanor Slater Hospital, with close to 200 patients on campuses in Cranston and Burrillville, is not in compliance with basic "Medicare conditions of participation."

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The implications are unclear, as CMS also wrote: "At this time, these findings do not affect the hospital's Medicare payments or its status as a participating provider of hospital services in the Medicare program."

The findings were obtained independently by The Journal. Charest has not made them public or commented on the long-awaited CMS report that dates back to a known visit in September and an "onsite complaint investigation" on Dec. 7.

The deficiencies fall under numerous categories, including "patient rights," "physical environment" and "infection prevention and control."

Reading through patients records, the investigators found, for example, that the hospital incorrectly recorded the "end of life," do-or-do-not resuscitate directive of at least one patient, failed to stay on top of physician-ordered tests kept on "an index card at the nurse's desk'' and was unable to provide any "documented evidence'' that one patient received 2 p.m. medications "as ordered by the physician."

They also noted after-the-fact entries to a "patient safety check assignment sheet'' for 15 of 15 patients on a single unit on the Cranston campus.

"During an interview with [an unnamed employee] on 9/13/2021 at 2:35 PM, she/he acknowledged that there was no evidence that the safety checks were performed."

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Why the state has not released the report

The McKee administration has been unwilling to disclose the CMS findings, saying it is waiting until the Jan. 31 deadline for the state to respond. But leaks to The Journal disclosed several of the major findings earlier this week.

On Tuesday, however, The Journal obtained the package of findings that led CMS to cite the hospital for a long list of failings spelled out in detailed reports.

The findings center in part on what happened to a woman identified only as "Patient ID #1."

A patient in the psychiatric wing of the hospital who was supposed to be on constant one-to-one observation managed to stockpile and then swallow a cupful of pills while three hospital staffers were chatting.

A subsequent review of the videotapes and other documentation from "12/5/2021 at 2:30 PM revealed that [the patient] ingested a 'cupful' of pills that s/he had 'evidently concealed over a period of time,' resulting in Patient ID #1 being transferred and admitted to an acute care hospital with the diagnosis of 'drug overdose'."

A doctor's order for "continuous 1:1 observation ... [is] the most intensive standard level of observation,'' the CMS report said.

"It assigns a staff member to constantly observe the patient. It will be used for patients that inflict self-harm, suicide ideation, and violent behavior ... [and it means] an assigned staff member must always be with the patient, including in the bathroom."

In this case, CMS said, "the hospital failed to properly observe a patient with a physician's order for 1:1 constant observation ... The hospital failed to follow their own policy for medication administration."

Even more basically, CMS questioned whether the Eleanor Slater Hospital is what its operating license says it is: a long-term care hospital.

CMS said a "review of correspondence, submitted to CMS on September 16, 2021, by [an unnamed employee], revealed that on April 27, 2021, [that employee] communicated concerns ... regarding the medical necessity of services to the current patients of the hospital."

Among the concerns: " 'Our hospital' exists to house people with complex social problems not for any medical purposes. We do not and cannot provide LTACH [another acronym used to reflect Long-Term Care Hospital] level of care."

This article originally appeared on The Providence Journal: Report: RI Slater hospital lapses reached 'immediate jeopardy' level