Zambarano cited by RIDOH following complaints on patient care

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BURRILLVILLE – The Rhode Island Department of Heath has cited Burrillville’s Zambarano hospital for several deficiencies with nursing services, including failure to follow proper medication and patient safety policies, as well as housekeeping and maintenance procedures.

The long-term acute care hospital received the 22-page summary of deficiencies following an investigation by state and federal authorities conducted in September and October.

The hospital, a unit of the state-run Eleanor Slater Hospital in Cranston, also failed to provide proper care to 72 percent of patients sampled in a recent survey, according to reports.

The evaluation reportedly followed complaints to the RIDOH regarding care, and noted that the hospital has not complied with the Nursing Services Condition of Participation, and that patients’ rights have not been met.

Zambarano was allowed to provide a plan of correction for the deficiencies, and the hospital’s response detailed the method to correct issues that included training for staff and better implementation of policies.

“The failure on the part of the staff to follow the Safe and Supportive Observation of Patients Policy has been addressed,” wrote the hospital.

Investigators reviewed hospital records for two specific cases in which patients ended up in emergency rooms in September, revealing a long list of failings, including check lists that were false and/or never completed.

Review of the check list for one patient with developmental disabilities for the date of August 31 revealed that staff marked the individual as being “checked,” at 7 a.m., 11 a.m., 3 p.m., 7 p.m., 11 p.m., and 3 p.m., when “the patient was transferred to the ER at 12:45 p.m. and did not return to the hospital until 9/3/19.”

That same day, the patient, who reportedly had a history of falls, was in the shower while hospital generators were being tested – a process the automatically closes all “fire doors,” – including the door to the shower room.  A behavioral therapist stated that the patient was left in her room at 10:30 a.m., and staff did not locate her on the floor of the shower until 12:10 p.m.

Policy dictates that staff must check on patients every 30 minutes.

Further, 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.

The report notes that the hospital’s housekeeping supervisor acknowledged that one shower was in need of being “scrubbed and repaired.”

“She was unable to produce evidence of when the shower was last cleaned,” states the report, printed on Friday, Nov. 1.

Another review showed that the hospital failed to follow medication and check-in procedures for a patient with hypothermia. Staff failed to monitor the patient’s temperature for seven days in September, including the 26th, 27th, and 28th. The same patient was sent to the ER for treatment on the 29th.

Zambarano was opened in 1905 as a sanatorium and currently serves 90 to 93 individuals living with developmental disabilities and co-occurring medical conditions. The hospital provides long-term acute and post-acute hospital level of care to patients with complex medical and psychiatric needs.

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