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Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 2 of 9 (Pt. #3, 6) medical records reviewed, that the Hospital failed to ensure interpretive services were provided to ensure patient's rights were met regarding information on patient care services.
Findings include:

1. The Hospital policy and procedure titled, "Patient Rights" (With a revised date of 10/2/06) was reviewed. It indicated under, "Attachment 1 Statement of Patient Rights and Responsibilities, Patient have the right to: ... To an interpreter and alternative communication methods when indicated..."

2. The Hospital policy titled "Interpreters-Foreign Language & Hearing Impaired" effective 7/1/12, was reviewed on 12/4/12. The policy indicated under "Special Instructions: 1. Identify and Record a patient's primary language and dialect upon admission a. Interpreter should be contacted and available to assist ... 5. Documentation when Interpreters provide services must include but is not limited to a. The date and time Interpreter was contacted and performed services ..."

3. The medical record of Pt #3 was reviewed. It indicated that Pt #3 presented to the Emergency Department on 9/10/12 with the chief complaint of Leg Wounds. The admission assessment for Pt #3 indicated "Interpreter required - Yes" and that Pt #3 used sign language to communicate. There was no documentation in the medical record of Pt #3 to indicate if an interpreter was offered or utilized.

4. The medical record of Pt #6 was reviewed. It indicated that Pt #6 was admitted on 7/20/12 with a diagnosis of Breast Cancer with Metastases. The admission assessment for Pt #6 indicated "Language - Spanish, Interpreter required - Yes." There was no documentation to indicate if interpretive services were offered or utilized except on 7/23/12 and 7/30/12.

5. During an interview with the Director of Risk Management, conducted on 12/4/12 at 1:35 PM, it was verbalized that if the patient requires interpretive services, the hospital is to utilize the hospital interpreter or the telephonic phone devices for interpreter services and that it should be documented in the medical record.

Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 2 of 9 (Pts #4, #6) medical records reviewed, the Hospital failed to ensure all patients were assessed/provided information related to advanced directives.
Findings include:

1. The Hospital policy and procedure titled, "Advanced Decision Directives: Durable Power of Attorney for Health Care (DPOAHC), Living Will, State of Illinois Do Not Resuscitate (DNR) Form" (with a Revised Date: 5/18/12) was reviewed. It indicated under, "SPECIAL INSTRUCTION - For inpatient and outpatient settings: the hospital will request information regarding advance directives and, if any, will honor advance directives. The hospital staff document whether or not the patient has an Advance Directive." The policy further indicated under "Procedure ... The hospital provides patients with written information about advance directives ... Upon request, the hospital refers the patient to resources for assistance in formulating advance directives ... On admission or as soon thereafter as the patient is able to respond..."

2. The medical record of Pt #4 was reviewed on 12/4/12. It indicated Pt #4 was admitted on 9/27/12 with diagnoses of Transient Ischemic Attack and Cerebral Vascular Accident. Documentation on the "Care Activity - Assessment" page indicated "Advanced Directive - No, If No, would you like to learn about Advance Directives - Yes (Consult)". There was no documentation in the medical record that indicated Pt #4 was provided the requested information about advanced directives or that a consult was made.

3. The medical record of Pt #6 was reviewed on 12/4/12. It indicated Pt #6 was admitted on 7/20/12 with a diagnosis of Breast Cancer with Metastasis. There was no admission assessment (which would have addressed advance directives) documented. There was no documentation that indicated Pt #6 was assessed/asked about any advance directives during her hospitalization.

4. During an interview with the Director of Risk Management, conducted on 12/4/12 at 1:45 PM, it was verbalized that Pastoral Services should provide and document that requested information was provided to all patients who request information on advance directives. It was further verbalized that all patients should be assessed to determine if they have or are interested in advanced directives.