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Based on review of policy and procedure, and 2 of 60 open and closed patient records reviewed, patients (#76 and #81), the hospital failed to provide translation services consistent with allowing full participation in their plan of care.

The facility serves a large Hispanic community, and employs many Spanish-speaking staff. The facility has a process by which to credential staff to act as interpreters when needed. In addition, the facility uses Language Line.

The hospital policy Translator Services, revised 5/2009 states in part, " Whenever patients are unable to communicate in English, or understand the instructions or directions of healthcare personnel, it is the responsibility of the nurse assigned to the patient to request suitable interpreter services. " Per policy, patients are encouraged to use interpreters, and should sign a waiver if refusing.

Patient #76 is a 28-year-old Spanish-speaking female admitted to the hospital on 10/23/2010 due to a 15-day bout of abdominal pain and vomiting of unknown etiology. Patient #76 was status post cholecystectomy one year ago. She was alert and oriented to three spheres.

Patient #76 was triaged at 12:12 am on 10/23/2010. An emergency department nursing note of 10/23 at 1:11 am states in part, "Patient has had gall bladder issues in the past. Not sure if she still has gall bladder or appendix. Pt ' s significant other at bedside for interpretation. " The facility cannot assess the quality of quantity of information when given through a family member or friend, and the nurse was unable to get a history due to the language barrier.

A nursing assessment of 10/23 at 1 pm identified " language " as a learning barrier, and that patient #76 learns via reading, listening, pictures, and demonstration. Review of the nursing care plan reveals a pre-printed " Communication " problem which is not filled-out for patient #76 needing an interpreter. Nursing assessed patient #76 as needing interpreter services, but this did not become a part of her plan of care.

A hospitalist note dated 10/23 at 2:05 pm reveals his examination findings, and states in part, "D/W (discussed with) pt. (patient) & English-speaking family at bedside. " A physician note of 10/24/2010 at 3:40 pm states in part, " Pt. seen & examined, c/o (complains of) abd (abdominal) pain after eating food. d/w (discussed with) English-speaking husband @ bedside. " The husband was actually patient #76 ' s boyfriend, who interpreted for the physician. No evidence that a certified hospital interpreter or language line was used to relate assessment findings to the patient is found.

On 10/25, this surveyor interviewed patient #76 through a certified hospital interpreter. Patient #76 states she told staff she needed an interpreter, but they, " Didn ' t have anyone yesterday (10/24). " She states that she had an interpreter on one day of her admission, but the "the father of her child and friends " have largely been interpreting for her. When queried regarding an MRI (magnetic-resonance imaging) consent printed in English which she signed, patient #76 states that a female staff informed her it was for MRI, that her signature was needed, and she signed the document. It is unclear where the MRI assessment information was obtained, but the information in the assessment prior to MRI is critical information and should come directly from the patient.

Patient #81 is a 27-year-old Hispanic male who came to this country three years ago, and largely speaks Spanish though he knows some words in English. Patient #81 was admitted to the facility mental health unit on 10/20/2010 after becoming agitated, delusional, and paranoid at home, and feeling family members were out to harm him. His diagnosis was Psychosis, r/o (rule out) Schizoaffective Disorder.

Patient #81 had a Spanish-speaking psychiatrist. His admission note states in part, " Their English is very limited " ....A cousin ___ is bilingual and will be available for further assessments and discharge planning. " Patient #1 ' s psychiatrist was able to complete his assessment.

On 10/20 at 9:42 pm, patient #81 began to escalate. He received haldol and ativan to calm him. However, it had little effect, and he banged his head against the glass in such a way that the glass broke, and he became combative when staff attempted to intervene. A telephone order for 4-point restraint was obtained at 10:25 pm, and he received more medication in an effort to calm him. He quickly fell asleep, and was removed from restraint within 15 minutes of initiation.

An RN on the unit called an emergency department physician to examine patient #81 ' s head. The physician ordered a CT, but also ordered that patient #81 be transported in restraint and patient #81 was taken to obtain a CT of the head which was negative. Nothing in the record indicates that patient #81 received translation services throughout the restraining events. The facility states that a Spanish-speaking counselor was present, though no notes or signatures by this counselor are found. No evidence of any translation during this event is found. Interview with patient #81 which was translated by his psychiatrist reveals that no one spoke to him in Spanish when he became upset and was placed in restraint.

The hospital failed to honor the rights of patient # 76 and 81 when it failed to provide them with consistent interpreter services, and for patient #76, used her significant other to convey personal health information to her.

Based on review of policy and procedure, and patient records, it is determined that in 2 of 5 restraint/seclusion patient records reviewed, staff had no rationale to restrain patients # 81, and 87.

Patient #81 is a 27-year-old Hispanic male who came to this country three years ago, and largely speaks Spanish though he knows some words in English. Patient #81 was admitted to the facility mental health unit on 10/20/2010 after becoming agitated, delusional, and paranoid at home, and feeling family members were out to harm him. His diagnosis was Psychosis, r/o (rule out) Schizoaffective Disorder.

On 10/20 at 9:42 pm, patient #81 began to escalate. He received haldol and ativan to calm him. However, it had little effect, and he banged his head against the glass in such a way that the glass broke, and he became combative when staff attempted to intervene. A telephone order for 4-point restraint was obtained at 10:25 pm, and he received more medication in an effort to calm him. A nursing note of 12 midnight states in part, " Dr. ___ was telephoned. He gave initial order for restraints and Benadryl 25 mg IM, Geodon 20 mg IM, prn. Pt. fell asleep quickly, and the 4-point restraint were removed after 15 minutes at 2240. The house doctor had not yet arrived. At 2325 writer called the ED to have a doctor examine him because pt. had been hitting his head- there was not evidence of injury, but an examination was called for. Dr. ___ ordered that the pt. be transported in 4-point restraints for a CT scan of the head. Pt. left the unit at 2325. A T.O. order (inappropriately timed) at 2230 states, " Transport pt. in 4-point restraints for CT-scan of head. " The order reveals no time limit, nor indication. At the time, patient #81 was sleeping, with no medical or behavioral necessity for restraint.

Patient #87 is a 25-year-old male with a history of bipolar illness who transferred to the hospital MHU after becoming agitated, and throwing furniture in a psychiatric hospital to which he was currently admitted. During evaluation, he threatened repeatedly to kill himself and others.

On 7/16/2010, patient #87 became agitated, and began punching a wall and banging his head against the wall. Once redirected, he informed staff that he would harm them. He was placed in 4-point restraint at 6:15 pm. A T.O. order of 7/16/2010 at 6:30 pm states, " Place patient on 4-point restraint for out of control behavior.

At 7:45 pm, patient #87 is noted as quiet. Staff had downgraded the restraints to 3-points, but he not taken out of restraint. Patient #87 was noted as quiet through 11:30 pm. Every 15-minute omissions in documentation occur, until he was noted quiet again at 2:30 am until 3:45 am. At that time he is noted as sleeping and was taken out of restraint. Staff had downgraded patient #87 to 2- point restraint at 11:15 pm, and one restraint from 2:45 am. However, staff kept him restrained based on his earlier statements of harm to others made between 6:15 and 7:15 pm of 7/16 when he is documented to have made his last threat. A Behavioral Restraint/Seclusion Q 15-Minute Flow Sheet note documented between 10:15 pm and 2 am state, " Pt. remains unpredictable. Makes threats of physical harm. " Unpredictability is not criterion for placement in or continuation of restraint. In addition, and according to documentation, patient #87 had made no threats since 7:15 pm.

An untimed, undated face-to-face by the house physician states in part, " 2-points for aggressive behavior & threats. " His findings state in part, " Pt. calm and cooperative, " and his plan for patient #87 was to, " Continue restraint protocol. " Staff did not reduce patient #87 ' s restraints to 2 until 11:15 pm, so this face to face was done at or following this time. Patient #87 had revealed no behavior requiring the use of restraint beyond 7:15 pm, yet was restrained for 8 ? hours beyond that time.

Based on review of policy and procedure, and 5 restraint/seclusion patient records, it is determined that no updates to care plans are found for 5 of 5 restraint /seclusion patients reviewed, # 81, 84, 85, 86, and 87 as evidenced by

A hospital policy Restraint/Seclusion Behavioral Health revised 2/2007 states in part, " The RN plans appropriate interventions and care for the patient in restraint/seclusion. The interdisciplinary plan of care is updated or amended as appropriate.

Patient #81 is a 27-year-old Hispanic male who came to this country three years ago, and largely speaks Spanish though he knows some words in English. Patient #81 was admitted to the facility mental health unit on 10/20/2010 after becoming agitated, delusional, and paranoid at home, and feeling family members were out to harm him. His diagnosis was Psychosis, r/o (rule out) Schizoaffective Disorder.

On 10/20 at 9:42 pm, patient #81 began to escalate. He received haldol and ativan to calm him. However, it had little effect, and he banged his head against the glass in such a way that the glass broke, and he became combative when staff attempted to intervene. A telephone order for 4-point restraint was obtained at 10:25 pm, and he received more medication in an effort to calm him. He quickly fell asleep, and was removed from restraint within 15 minutes of initiation. No evidence of an update to patient #81 ' s care plan is noted.

Patient #84 is a 22-year-old male admitted to the MHU on 5/27/2010 after becoming aggressive at his placement, and shoving a staff member. On 6/12/2010 at 1:15 am, patient #84 was placed in 4-point vinyl restraint after becoming agitated and throwing furniture at staff. Patient #84 remained in restraint for one hour. No evidence of an update to patient #84 ' s care plan is noted.

Patient #85 is a 23-year-old male admitted to the mental health unit (MHU) on 5/12/2010 after taking and crashing the family car. The police chased him and brought him in via emergency petition. On assessment, patient #85 was delusional and hyper-religious, believing he was has an urgent message from God, for someone in DC. Patient #85 was reported by his mother to have a history of psychiatric care with one hospitalization, and had recently been talking to himself. He was given a diagnosis of Psychosis NOS (not otherwise specified), and PCP intoxication. On 5/13 at 10:50 am until 5:15pm, patient #85 placed in 4-point restraint for 6 hours and 25 minutes. No evidence of an update to his care plan is noted.

Patient #86 is a 38-year-old female with a history of bipolar disorder who had been inpatient at the MHU one week prior, was noncompliant with medication after discharge, and was subsequently found wandering in traffic. She was taken to another hospital via emergency petition on 10/3/2010. She requested transfer to the former hospital, and this was done. Prior to transfer, she spit on staff and broke a window when denied a cigarette. Patient #86 reported that she was pregnant with twins, and that the hospital made her miscarry.

On 10/4/2010 at 5:15 pm, patient #86 was paced in 4-point vinyl restraint due to severe agitation and two assaults on staff. She remained in restraint for 2 hours and 15 minutes.

On 10/6/2010 patient #86 became severely agitated and threatening to her psychiatrist. She took the chart from the MD, threw it, and tore up the contents. Patient #86 was placed in seclusion from 2 to 4 pm. No evidence of an update to patient #86 ' s care plan is noted for the restraints or seclusion.

Patient #87 is a 25-year-old male with a history of bipolar illness who transferred to the hospital MHU after becoming agitated, and throwing furniture in a psychiatric hospital to which he was currently admitted. During evaluation, he threatened repeatedly to kill himself and others.

On 7/16/2010, patient #87 became agitated, and began punching a wall and banging his head against the wall. Once redirected, he informed staff that he would harm them. He was placed in 4-point restraint at 6:15 pm where he remained until 9 ? hours. No evidence of an update to patient #87 ' s care plan is noted.

Based on review of policy and procedure, and 5 behavioral restraint records, 1 of 5 records, patient #87 does not have orders for restraint noted in the record as evidenced by:

Patient #87 is a 25-year-old male with a history of bipolar illness who transferred to the hospital MHU after becoming agitated, and throwing furniture in a psychiatric hospital to which he was currently admitted. During evaluation, he threatened repeatedly to kill himself and others.

On 7/16/2010, patient #87 became agitated, and began punching a wall and banging his head against the wall. Once redirected, he informed staff that he would harm them. He was placed in 4-point restraint at 6:15 pm.

An initial telephone order of 7/16/2010 at 6:30 pm states, " Place patient on 4-point restraint for out of control behavior. A untimed House Physician Consultation Sheet appears in the record which states in part, " Two points for aggressive behavior & threats. " Pt. calm & cooperative, " with a plan to " Continue restraint protocol. " No order appears in the record at10:30 pm to continue restraint, nor does an order appear in the record at 2:30 am to continue restraint. An untimed order sheet, filled-in by a nurse states in part, " Patient out of wrist restraint on right arm 0245, " and " d/c 0345. " Patient #87 was without an order for restraint from 10:30 pm of 7/16 until 3:45 am of 7/17, a total of approximately 5 hours and 15 minutes.

Based on review of hospital policy, and patient records, 2 of 5 patients, #81, and 87 received an order with no time limitations noted as evidenced by:
Patient #81 is a 27-year-old Hispanic male who came to this country three years ago, and largely speaks Spanish though he knows some words in English. Patient #81 was admitted to the facility mental health unit on 10/20/2010 after becoming agitated, delusional, and paranoid at home, and feeling family members were out to harm him. His diagnosis was Psychosis, r/o (rule out) Schizoaffective Disorder.

On 10/20 at 9:42 pm, patient #81 began to escalate. He received haldol and ativan to calm him. However, it had little effect, and he banged his head against the glass in such a way that the glass broke, and he became combative when staff attempted to intervene. A telephone order for 4-point restraint was obtained at 10:25 pm, and he received more medication in an effort to calm him. A nursing note of 12 midnight states in part, " Dr. ___ was telephoned. He gave initial order for restraints and Benadryl 25 mg IM, Geodon 20 mg IM, prn. Pt. fell asleep quickly, and the 4-point restraint were removed after 15 minutes at 2240. the house doctor had not yet arrived. At 2325 writer called the ED to have a doctor examine him because pt. had been hitting his head- there was not evidence of injury, but an examination was called for. Dr. ___ ordered that the pt. be transported in 4-point restraints for a CT scan of the head. Pt. left the unit at 2325. A T.O. order (inappropriately timed) at 2230 states, " Transport pt. in 4-point restraints for CT-scan of head. " The order reveals no time limit, nor indication. At the time, patient #81 was sleeping, with no medical or behavioral necessity for restraint.


Patient #87 is a 25-year-old male with a history of bipolar illness who transferred to the hospital MHU after becoming agitated, and throwing furniture in a psychiatric hospital to which he was currently admitted. During evaluation, he threatened repeatedly to kill himself and others.

On 7/16/2010, patient #87 became agitated, and began punching a wall and banging his head against the wall. Once redirected, he informed staff that he would harm them. He was placed in 4-point restraint at 6:15 pm. Patient #87 continued to threaten and stated he would kill staff once he was released from restraint.

A telephone order of 7/16/2010 at 6:30 pm states, " Place patient on 4-point restraint for out of control behavior. The order shows no time limitation for restraint, and though signed, does not have a date or time with the signature.

No order appears in the record for 10:30 pm when a continuation was due, nor at 2:30 am on 7/17.

Based on policy and procedure, and patient records, 1 of 5 patients reviewed, #87 was kept in restraint beyond the time when he represented a danger to self and other.

Patient #87 is a 25-year-old male with a history of bipolar illness who transferred to the hospital MHU after becoming agitated, and throwing furniture in a psychiatric hospital to which he was currently admitted. During evaluation, he threatened repeatedly to kill himself and others.

On 7/16/2010, patient #87 became agitated, and began punching a wall and banging his head against the wall. Once redirected, he informed staff that he would harm them. He was placed in 4-point restraint at 6:15 pm. A T.O. order of 7/16/2010 at 6:30 pm states, " Place patient on 4-point restraint for out of control behavior.

At 7:45 pm, patient #87 is noted as quiet. Staff had downgraded the restraints to 3-points, but he not taken out of restraint. Patient #87 was noted as quiet through 11:30 pm. An omission in documentation occurs, until he was noted quiet again at 2:30 am until 3:45 am. At that time he is noted as sleeping and was taken out of restraint. Staff had downgraded patient #87 to 2- point restraint at 11:15 pm, and one restraint from 2:45 am. However, staff kept him restrained based on his earlier statements of harm to others made between 6:15 and 7:15 pm of 7/16 when he is documented to have made his last threat. A Behavioral Restraint/Seclusion Q 15-Minute Flow Sheet note documented between 10:15 pm and 2 am state, " Pt. remains unpredictable. Makes threats of physical harm. " Unpredictability is not criterion for placement of or continuation of restraint. In addition, and according to documentation, patient #87 had made no threats since 7:15 pm.

An untimed, undated face-to-face by the house physician states in part, " 2-points for aggressive behavior & threats. " His findings state in part, " Pt. calm and cooperative, " and his plan for patient #87 was to, " Continue restraint protocol. " Staff did not reduce patient #87 ' s restraints to 2 until 11:15 pm, so this face to face was done at or following this time.

Patient #87 had revealed no behavior requiring the use of restraint beyond 7:15 pm, yet was restrained for 8 ? hours beyond that time.

Based on review of hospital forms and patient records, the hospital initial order form does not address all evaluation criteria, and for 1 of 5 restraint/seclusion patients reviewed, #87 did not have appropriate face to face assessments.

The hospital has an Initial Order for Behavioral Restraint/Seclusion form which states at the bottom, " Based on my examination, and assessment of the patient, and consideration of his/her current mental and physical status, use of restraint/seclusion is indicated for the reason specified above. The reason stated above refers to the justification for restraint/seclusion. The statement does not meet the regulatory directives for evaluation as stated in 482.13 (e) (12), as it does not address the patient reaction to the intervention, nor the medical and behavioral condition of the patient.

Patient #87 is a 25-year-old male with a history of bipolar illness who transferred to the hospital MHU after becoming agitated, and throwing furniture in a psychiatric hospital to which he was currently admitted. During evaluation, he threatened repeatedly to kill himself and others.

On 7/16/2010, patient #87 became agitated, and began punching a wall and banging his head against the wall. Once redirected, he informed staff that he would harm them. He was placed in 4-point restraint at 6:15 pm. A telephone order written on a general order sheet of 7/16/2010 at 6:30 pm states, " Place patient on 4-point restraint for out of control behavior. A nursing note of 6:30 pm states, " Dr. ___ did face to face. " No documentation is found of this face to face.

An untimed, undated face to face by the house physician states in part, " 2-points for aggressive behavior & threats. " His findings state in part, " Pt. calm and cooperative, " and his plan for patient #87 was to, " Continue restraint protocol. " Based on the fact that staff did not down-grade patient #87 ' s restraints to 2 until 11:15 pm, this face to face was done at or after 11:15 pm. No documentation reveals that patient #87 had a face-to-face within one hour of restraint at 6:15 pm.

In 6 of 60 open and closed records reviewed (patients #29, 30, 31, 32, 33, and 34), the hospital failed to ensure that all patient medical record entries were legible. Examples included are:

Patient #29 was a 54 year-old female admitted with acute psychosis from 08/04 through 08/12. Illegible entries were noted in the medical record including progress notes on 08/04 at 1345, 08/05 at 1055, and 08/10 at 1100. Illegible orders were also noted on 08/04 at 1325, 03/05 at 1045, and 08/12 at1100.

Patient #30 was a 72 year-old female admitted 07/05 through 08/09. Patient #30 expired after developing sepsis related to bowel perforation during insertion of a drain. Illegible entries were noted in the medical record including illegible orders on 07/13 at 2130, and an illegible progress note on 07/09.

Patient #31 was an 80 year-old female admitted 10/11 with a length of stay through 10/31. The medical record revealed an illegible order entered on 10/22.

In 9 of 60 open and closed medical records reviewed (patients # 31, 33, 34, 35, 51, 52, 57, 58 and 59), the hospital failed to ensure that all verbal orders including telephone orders were authenticated in a timely manner. For example:

Patient #31 was an 80 year-old female admitted to Washington Adventist Hospital from 10/11 through 10/31. The medical record included a telephone order entered at 0530 on 10/21 that was never signed off by a physician.

Patient #33 was a 62 year-old male admitted 10/14. The medical record included telephone orders entered on 10/18 at 1830, and 10/20 at 0615, both of which were never signed off by the physician.

Patient #34 was a 36 year-old female admitted 10/08. The medical record included 1 telephone order entered on 10/16 at 1415 that was never signed off by the physician, and a telephone order for restraint entered on 10/20 at 1330 but not signed off until 10/28 at 1115.

Patient #35 was a 58 year-old male admitted on 10/04. The medical record revealed 2 telephone orders never signed off by the physician (10/18 at 1430 and

Based on a tour of the kitchen and interview with staff on October 25, 2010, hygiene and maintenance issues were noted that should have been addressed through the oversight of the Director as evidenced by:

During the tour of the kitchen on October 25, 2010, it was revealed that there was an accumulation of grease and debris beneath the cooker/steamer units and a deep fat fryer. In addition, the fiberglass insulation on the steam supply and return lines was falling apart and leakage of water from the steamers was pooling underneath of the cooker steamer units.

In addition to the concern regarding the equipment leakage and sanitation, it was noted that the lighting fixture above the ovens was not functional . Interviews of hospital managers revealed that the light may be functional but the lighting element may have burned out.

All directors must assure that ongoing program of maintenance continues to provide for food service facilities that are safe and where the function of equipment is maintained. In addition, the director must must assure that proper housekeeping and sanitation will be provided to maintain clean and hygienic food service areas.