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‘Go shoot yourself’: Eleanor Slater Hospital review reveals ‘dangerous environment’

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PROVIDENCE, R.I. (WPRI) — Gov. Dan McKee on Wednesday released a detailed list of health and safety issues at Eleanor Slater Hospital, showing five immediate threats to life including a dispute in which a patient was told to “go shoot yourself.”

The issues were cited after last week’s review of the embattled state-run health care system by The Joint Commission, a national accrediting agency that subsequently issued a preliminary denial of accreditation for the hospital.

Joint Commission chief operating officer Mark Pelletier described the conditions at Eleanor Slater as posing a “serious threat to public or patient health and safety,” according to a letter he sent state officials last Friday.

The report detailed five major issues related to the hospital’s current conditions, including a lack of maintenance that’s resulted in a “dangerous environment,” a pattern of not responding to a long-existing medical-gas issue and an overall failure to create a culture of safety.

“Care, treatment and/or services were provided in a manner and in an environment that posed risk of an ‘immediate threat to health,’ or ‘immediate threat to life,'” wrote agency officials, citing technical terms that describe the least safe environment possible.

In another section of the report, The Joint Commission detailed “a decrepit building with peeling paint, many fallen and broken ceiling tiles, rust in the bath and showers, broken call cords, doors that don’t close, medication room equipment trays mislabeled and cracked and defective flooring, unkept grounds and dangerous trip and fall hazards at the entries.”

“One physician stated that ‘the only time work on those buildings is performed is when The Joint Commission arrives,'” agency officials reported.

Another finding showed The Joint Commission reviewed an incident from May 2019 — on Mother’s Day — when a registered nurse determined they were short staffed and couldn’t send a patient upstairs for dinner. According to the report, the patient complained and the nurse became “aggressively defensive.”

“The exchange escalated and the hospital report alleges that the nurse said the patient should ‘go shoot yourself,'” before using a racial slur to describe herself, adding, “Come at me and see what happens.”

The nurse denied making the racial statements, despite witness statements, and the union filed a wrongful termination suit after the nurse was fired. The arbitrator sustained the union’s grievance and ruled “the termination was without cause.”

“The nurse is currently employed at [Eleanor Slater],” according to the report.

Rhode Island now has about 20 days left to resolve the many issues if it wants to save its accreditation — a key requirement to receiving tens of millions of dollars in federal funding each year. After releasing the report, McKee denounced the current state of affairs and said his administration is working to improve operations “for patients and families.”

“I am deeply disturbed and frankly disgusted with the findings of the Joint Commission’s preliminary report,” McKee said in a statement. “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.”

McKee said Tuesday he’s confident they will be able to figure out solutions before the agency comes back to re-examine the hospital.

“We feel like we’ll meet that timeline,” McKee said.

Richard Charest, director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, which oversees Eleanor Slater, also expressed confidence that the state would not lose its accreditation.

“When we fix these issues, The Joint Commission will do a follow-up review,” Charest said during a Senate Committee Oversight committee hearing Monday. “It’s my expectation they will remove the preliminary denial of accreditation.”

Charest also said many of the issues tied to the hospital’s building conditions were cosmetic, such as missing and dirty ceiling tiles and chipped paint on the walls, which could be fixed easily.

In a section of the report that detailed many of those deteriorating conditions, Eleanor Slater staff reportedly told The Joint Commission that the “repairs are neglected and not supported by leadership because of a planned closure of the building.” The sentiment echoes an idea that first formed in 2019 under former Gov. Gina Raimondo, although her plans shifted several times publicly in the year that followed.

McKee has since put a hold on all future plans for the hospital, saying his proposal for what should come next is slated to come out by the end of next week.

In the oversight hearing, lawmakers more broadly scrutinized why the hospital hasn’t kept up with maintenance at Eleanor Slater, arguing the General Assembly has provided the health care system with tens of millions of dollars for capital improvements.

Chairman Louis DiPalma, D-Middletown, took aim at the hospital’s medical-gas system that was cited for having problems in multiple inspections during recent years. He questioned why those issues weren’t resolved until after the state Fire Marshal cited them as faulty earlier this year.

“Why wasn’t it addressed?” DiPalma asked. “Why do we even have the people come in and do the med-gas testing if we don’t care about it?”

Chris Feisthamel — who’s serving as the hospital’s chief operating officer — pushed back, saying that they do care about the facilities but that the fire marshal’s interpreted the safety rules in “a more cautious manner,” which is why they worked to fix the issue this year.

“First and foremost, we do care,” said Feisthamel, whose work history has come under recent scrutiny after Target 12 revealed records that raised significant questions about his job status.

But State Sen. Jessica de la Cruz, R-North Smithfield, challenged Feisthamel’s explanation, citing an email he set in January 2020 that showed he had a different rationale. Target 12 has obtained and independently verified the email.

“The med gas needs significant repairs — the outlets all need to be changed and there are shut off valves to add to the system,” Feisthamel wrote at the time to the hospital’s former CEO, Cynthia Huether, and Lisa Greenlund, who serves as Eleanor Slater’s safety officer.

“We don’t have the time to repair it and we don’t want to sink a bunch of money into an old building,” he added. “At one point, we were told that it would be about $1M to fix the system.”

In its report, The Joint Commission cited the hospital for failing to respond to issues related to the med-gas system, even though concerns had been raised multiple times in the past.

“There was no evidence leadership had responded to multiple instances of process failures relating to patient and/or environmental safety,” wrote agency officials. “Patient safety and environmental process failures were the serious medical gas and life safety code issues dating back to 2015 at Zambarano Hospital.”

Overall, The Joint Committee painted a bleak picture of the hospital’s culture of safety, explaining Eleanor Slater’s last survey of staff related to this issue was completed in 2018. And while an action plan started nine months later, it “lacks specific data on results from the recommended changes resulting from the plan.”

“There is no planned follow-up survey,” agency officials wrote, also noting the hospital’s governing body hasn’t met since October 2020. “A review of the prior minutes since the action plan was begun lack any mention of staff safety culture assessments since the onset of the action plan in 2019.”

For some lawmakers, including state Sen. James Seveney, D-Portsmouth, the idea of fixing cosmetic issues at the hospital within three weeks seems somewhat realistic. But the senator expressed skepticism when it came to the more systemic issues that The Joint Commission cited in its report.

“I’m concerned whether the culture of safety is something that can be fixed in 20 days,” Seveney said.

Eli Sherman ( is an investigative reporter for WPRI 12. Connect with him on Twitter and on Facebook.

Copyright 2021 Nexstar Media Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.


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