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9901 MEDICAL CENTER DRIVE

ROCKVILLE, MD 20850

PATIENT RIGHTS: GRIEVANCES

Tag No.: A0118

Based on a review of Patient Rights documents given to patients, it was determined that the hospital failed to inform patients on how to file a grievance.

Review of patient admission materials revealed no process by which the hospital informed patients on how to file a grievance. While a review of actual grievances revealed a proactive process, no evidence of patient information related to grievance processes was found.

PATIENT RIGHTS: INFORMED CONSENT

Tag No.: A0131

Based on a review of hospital policy "Consent" Revised 1/15/2019 and 7 open and 5 closed records, it was determined that for patients #4, and #7, no certification of incapacity was found prior to providers seeking consent from surrogate decision makers.

Review of hospital policy "Consent" Revised 1/15/2019 revealed in part, "POLICY: It is the right of every patient, in collaboration with his/her provider to make informed decisions about medical treatment that reflects his/her wishes."

Patient #4 was a 70+ patient admitted in February 2019 due to shortness of breath. Patient #4 spoke a dialect for which two attempts at translation service failed to communicate effectively, so the hospital used family interpretation.

Patient #4 required a procedure for which consent was needed. No incapacity statement was found in the record related to evaluation for patient #4's ability to make decisions. Instead, the consent for the procedure was signed by the family member who was acting as an interpreter. The Consent of 2/11/19 at 4:11 pm had a pre-printed section which stated, "If the patient is a minor, has mental incapacity, or unable to give consent, complete this section:" and, "I further certify that the patient is unable to give consent because: The family member write, "(patient) is too weak," and under a pre-printed statement "The procedure was explained to me, and I am authorized to consent for him/her because." The family member response to the statement indicated that the signing surrogate was the (family).

The hospital failed to utilize the only effective interpreter to help assess patient #4's understanding of the consent, or certify patient #4's incapacity status prior to obtaining consent from patient #4's surrogate.

Patient #7 was a 70+ patient who presented to the hospital in February 2019 due to a fall with fracture. Patient #7 was known to have some cognitive deficits, though at least two physician notes found patient #7, " ...with possible dementia, but currently pt is oriented with good insight," and, " ...with dementia, but currently pt is oriented with good insight."

A surgical consent the following day at 0730 revealed the pre-printed portion in part as, "If the patient is a minor, has mental incapacity, or unable to give consent, complete this section" "I further certify that the patient is unable to give consent because: The surrogate wrote, "Of confusion." The consent further stated, "The procedure was explained to me, and I am authorized to consent for him/her because:" The surrogate wrote, "I am his (significant other)." No actual capacity assessment was found which certified patient #7 to lack capacity prior to obtaining consent from patient #7's surrogate.

Following review of documentation for patients #4, and #7 it was demonstrated that while the hospital had a comprehensive and instructive Consent policy, hospital providers failed to meet regulatory requirements related to assessments for capacity prior to seeking surrogate decision-making.