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Based on a review of 10 open and 3 closed medical records, staff interviews, and observations it was determined that the hospital failed to allow Patient #12 (P12 ) the opportunity to participate in the pain management plan as evidenced by inconsistently documented pain assessments, a delayed transfer to Labor and Delivery (L&D) which was equipped to offer more consistent pain management, and the lack of evidence that any other medications were offered to the patient prior to transfer.

P12 was a 25+ year old patient who presented to Labor and Delivery for induction of labor (the stimulation of uterine contractions during pregnancy before labor begins on its own to achieve a vaginal birth). P12 was admitted to a High Risk Perinatal Unit (HRP) and started on medication to induce labor. According to documentation in the medical record, under the section for Birth plan/requests, the patient's stated wishes for anesthesia/pain medication were "Epidural, IV narcotic, Offer medication if patient uncomfortable."

Once labor began to progress, the physician documented that the "Patient is feeling much stronger contractions, will transfer to L&D," and wrote an order for transfer.

The patient was not transferred to Labor and Delivery for 20+ hours after that note was written. During that time, nursing documented that the patient's levels of pain were 4-6 on a 10 point scale with assessments taking place inconsistently at intervals of 2hrs, 5hrs and at one point 7 hours. No evidence was found to show that the patient was offered any type of medication for pain. Further review of the record revealed nursing documentation that stated, "Patient and husband upset and concerned that the transfer to L&D was taking too long." Once the patient was transferred to Labor and Delivery, documentation indicated that an Epidural was implemented immediately.

Observation of the Obstetrical Unit and subsequent interview with the Director of the Labor and Delivery Unit was conducted on 7/3/19. The HRP unit was a separate unit from Labor and Delivery and during the interview the Director stated that patients can only receive an Epidural on Labor and Delivery, however oral, intravenous, or intramuscular medications could be given on the HRP unit.

P12 had a birth plan that included preferences for pain relief. The patient complained of pain consistently throughout her induction. However, no evidence was found that the patient was offered any type of pain medication during a 3+ day induction and a 20+ hour delay in being transferred to a higher level unit.

Based on a review of the hospital consent policy (approved 03/26/2016) 10 open and 3 closed patient records, staff interview and hospital policy for interpreter Services, it was determined that the hospital failed to access guardian consent for Patient #2's (P2) surgery. The hospital also failed to provide interpreter services for Patient #10 (P10) that would have allowed the patient the right to refuse or request treatments, to establish a baseline including a medical history and to determine P10's understanding of the plan of care.

1) Review of the hospital consent policy revealed in part, "Informed consent is a process by which fully informed patients participate in choices about their health care," and, "Informed consent includes a discussion of the following (in part): "...The relevant risks, benefits, and side effects related to alternatives including the possible results of not receiving care, treatment, and services."

Patient #2 (P2) was a 60+ year old disabled patient with a court-appointed guardian of person due to P2's sustained inability to perform higher cognitive functions or to make informed, appropriate decisions. P2 was seen by a surgeon in February 2019 for a History and Physical (H&P) for possible surgery. P2 presented at that time with a former family member who was not the guardian. However, the surgeon accurately documented that P2 had a guardian, identified the guardian agency, guardian name, and contact information.

The surgeon documented counseling P2 and the former family member regarding possible surgery pending the results of a biopsy that had been obtained that day. Subsequent biopsy results revealed a possibility of cancer. A decision for surgery was made and a date was scheduled without informing the guardian.

The History and Physical was updated seven days prior to surgery by a Physician Assistant who documented in part, "Reviewed preop (pre-operative) instructions-see instructions below. The patient indicates understanding of these issues and agrees with the plan." P2 did not have the legal capacity to agree with the plan

On the day of surgery, the consent for surgery and anesthesia was signed by P2 at 1050, The consent revealed an area in which to document substitute consent including guardianship, which was left blank. The consent also revealed an area titled "II. Physicians Confirmation of Informed Consent" which was signed at 1045 by the surgeon who had previously documented knowledge of, and detailed information regarding, P2's guardian. Surgery proceeded without the consent of P2's guardian, and only following surgery, did the guardian become aware of the surgery.

Following review of all documentation, there was sufficient information in the medical record which identified that P2 had a guardian, and gave contact information regarding that guardian. However, the hospital failed to obtain required guardian consent for P2's surgery.

2) P10 was a 40+ year old patient who presented to the Emergency Department (ED) after an injury at work. The patient was admitted the following day secondary to a chronic condition that required continued observation and medication to manage. The intake form, ED nursing assessment, and admitting assessments listed the patient's preferred language as [not English]. However, under the "interpreter needed" section, the answer was listed as "no".

A Case Management note four days into the patient's stay stated "[not English] speaking patient, using Interpreter services, patient often confused about questions being asked." No other documentation was found in P10's medical record to show that interpreter services were used at any other time during the patient's 14+ day stay in the hospital.

Further review of nursing and social work documentation revealed multiple entries including "patient unable to report self-pain," "confused," "speech difficult to understand," "not following any commands, talking a whole lot but not making any sense" and "[non-English]-speaking, does not follow complete commands."

Without an interpreter, it was not possible to determine whether the patient's lack of following commands, inability to be understood, or level of confusion was due to a language barrier, the patient's medical condition or a combination of both. Consequently, P10 was unable to meaningfully participate in P10's own care.

Based on a review of 10 open and 3 closed patient records, it was determined that for outpatient radiology patient #1 (P1), the radiologist failed to accurately document how many biopsy samples were taken during a radiology guided breast biopsy and failed to describe the post-procedure condition of the wound or the unanticipated need for stitches.

Patient #1 (P1) was a 75+ year old who presented to the outpatient radiology department for a radiology-guided biopsy of the breast. A Radiologist procedure note revealed in part, " ...Approximately 12 core specimens were obtained. These were sent to pathology for further evaluation ..."

Review of a technician note related to the procedure revealed in part under Order Comment: "[calcified lesion] very superficial and close to nipple... [Calcified lesion] kept moving to the left. Dr. ___ had to use hemostat and stitches (from [another department])."

No documentation in the radiologist's procedure note indicated any procedural complications including the creation of a wound that necessitated the placement of stitches, nor was there a description of the wound. In addition, the number of biopsy punctures was not accurately reflected in the record.