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Safety violations, verbal abuse outlined in Eleanor Slater Hospital report

“I am deeply disturbed and frankly disgusted with the findings of the Joint Commission’s Preliminary Report,” the governor said

The Eleanor Slater Hospital in Cranston, Rhode IslandLane Turner/Globe Staff

PROVIDENCE — There were no staff members outside monitoring patients at the state-run hospital’s Zambarano Campus when inspectors arrived at 10 a.m. on Wednesday, June 17. The inspectors say they had to help stop a patient in a powered wheelchair from tipping over when one of the wheels got stuck in a pothole. Inspectors said it was unclear how long the patient had been there, tilted over and unable to move.

“The four of us were able to free her and safely place her in the center of the roadway,” the inspectors wrote in their 45-page report, in which a team from the Joint Commission on the accreditation of hospitals issued a “preliminary denial” of accreditation to Eleanor Slater Hospital.


In another incident, a staff member hurled the N-word at a patient. The inspectors were told it was “not unusual” to see mice in the buildings. And they noted “multiple instances” of failures to address safety issues

The concerning observations about patient abuse and safety take up 26 pages of the report, made public by Governor Dan McKee’s office on Wednesday.

“I am deeply disturbed and frankly disgusted with the findings of the Joint Commission’s Preliminary Report,” the governor said in a statement Wednesday. “The report is preliminary and highlights issues that have not been adequately addressed over many years.”

“My team is doing everything possible to address these deficiencies so that the Joint Commission’s final report will make the recommendation to maintain our accreditation,” he said. “Secretary (Womazetta) Jones, Director (Richard) Charest, my staff and I are working to improve operations at Eleanor Slater Hospital for the patients and their families.”

The state has been given 23 days, beginning June 19, to put in place a “corrective strategy,” and officials said on Tuesday that they expect to meet that deadline.


“We are going to activate the resources that it takes to make sure that we maintain the accreditation,” McKee said Tuesday.

The report released by the governor on Wednesday details incidents that were documented by inspectors during their visit as well as incidents which happened in the past but were previously undisclosed. Those incidents include:

  • A nurse became “aggressively defensive,” telling the patient, “Go shoot yourself.” As the incident escalated, the report says the nurse then told the patient “you want to treat me like a street [N-word] then come at me and see what happens.” The nurse was terminated after a review in July 2019, but the nurse denied making racial statements and the union filed a wrongful termination suit. The nurse is currently employed at Eleanor Slater Hospital.
  • Inspectors noted that staff told them that it was “not unusual to see mice on the unit running along the base of the wall and under the radiator boxes.”
  • There was no documentation showing that a certified nursing assistant who assisted a dentist in the Dental Clinic had received education or training to “safely and appropriately develop dental X-rays.” The CNA told inspectors that the dentist had given her verbal instruction.
  • A group bath had a severed emergency pull cord in the shower area which could not have been reached in case of a fall.
  • Inspectors said that there was “no evidence” that leadership had responded to multiple instances of process failures relating to patient or environmental safety.
  • Floor tiles were loose in the radiology suite that created a hazard. The surveyor noted that they were able to lift the tile from the floor with just the edge of their shoe. Other defects in that unit included peeling paint and door latches were on the floor. The medical director allegedly said that repairs in the patient care environment were usually not completed “even when the repairs are not expensive and despite repeated requests for repairs and upkeep were sent in through the normal work order channels.”
  • In eight of 28 employee files that were reviewed, primary source verification of each staffer’s credentials occurred after the renewal date. This applied to two infection preventionists, three nurses, a certified nursing assistant, and two radiology technicians.
  • Measuring syringes were attached to medication in a refrigerator. Staff told inspectors that the syringes are used repeatedly and washed in between uses. However, inspectors said there was “a visible pink solution in the syringe tip.”
  • In a medication room, there was a liquid in an open, unlabeled cup on a tray with a patient ID card. The nursing supervisor was unable to tell inspectors what the liquid was.
  • A COVID-19 vaccine card was given to a patient without the date of their dose being administered and the patient’s name was left blank.

The recommendations for the state-run hospital will be listed in the official report from the inspectors to the state. You can read the entire report here.

Alexa Gagosz can be reached at alexa.gagosz@globe.com. Follow her on Twitter @alexagagosz and on Instagram @AlexaGagosz.