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Based on review of the medical records, staff interviews, policies and procedures, it was determined that the hospital failed to obtain informed consent or explain to patient #14 information regarding the surgical procedure, risk and benefits and plan of care, when it failed to provide him with translator services, having identified that the patient spoke and understood limited English and that his primary language was Spanish

Patient #14 had a CT guided needle lung biopsy for a lung mass on 7/19/2013, which was complicated by right sided collapsed lung. A chest tube was inserted and the patient kept overnight. The admission assessment by the nurse on 7/19/13 at 1:14 PM revealed the patient was alert and oriented x3, Spanish speaking, and understands a little English. Under "Education" in the same assessment, learning barriers is written "Non-English Language." In addition, it noted that the family assisted with education. The pre-operative procedure verification checklist under level of consciousness the patient is noted as alert and next to other is written "needs daughter to translate."

The patient's rights and responsibilities policy ADMN 0100 under policy part D-Patient Rights, under #8a communication states: when the patient (patient's legally authorized representative) has low English proficiency (LEP), interpreter service will be provided through telephone interpreter services. The policy ADMN 0101 Non-English Speaking Patient under policy states the medical center will provide free services to low English proficiency (LEP) customers of their health care services. The policy further outlines a quick reference guide on how to access the Tele-Interpreters 24 hour Telephone Language Services. Although the hospital identified the patient had low English proficiency they did not access the interpretive services to provide and explain in a language or manner that the patient (or the patient's representative) could understand the health care services, patient options, risk and benefits of the procedure, care plan and discharge plans.

The hospital failed to inform patient #14 of his rights, care, treatment, services, and plan of care in a language he could understand. The assessments and explanations of complex treatment, procedures, and care were left to the patient's daughter to explain to the patient. The procedure was elective and the consent was obtained by the physician and nurse using the daughter to translate. With the daughter translating, including the explanation of the procedure, risk, benefits, and plan of care it not known if the patient's daughter translated in a manner that the patient was given the information so as to give informed consent for the procedure or whether the patient fully understood the plan of care, his options and risk and benefits of the procedure. There is no indication in the medical record that the telephone interpretive services were offered or used to assist the patient and his family in understanding his care, treatment and services.

Patient #1 is a 41 year old male admitted to Meritus Medical Center on April 12, 2013 for a dysfunctional gastrostomy tube and recurrent ventral incisional hernia. Patient #1 also had past surgical history of prior endoscopic gastrostomy tube placements, multiple incisional hernia repairs with mesh implantation, traumatic brain injury and spastic quadriplegia. Patient #1 was subsequently taken to surgery and underwent ventral hernia repair with mesh implants and replacement of the gastrostomy tube. Documentation indicates that patient #1 tolerated the procedure without complications and was subsequently transferred to an inpatient unit for observation/monitoring with expectation that patient #1 would be discharged to home after a 23 hour stay. Patient #1's father remained at the bedside.
On further review of the medical record, it was determined that Patient #1 remained stable until 11:00PM when his oxygen saturation begin to drop despite receiving oxygen via nasal cannula. Initially Patient #1's oxygen level dropped to 91% (normal range 92-100%) and his breath sounds were coarse, however, by 12:01 on April 13, 2013 Patient #1's oxygen level dropped to 71% and then 60%. A call was placed to respiratory therapy for assessment. However, at the time the respiratory therapy team arrived to the unit Patient #1 had stopped breathing and an apical pulse was unable to be detected. At that time Patient#1's father who was at the bedside requested no code (CPR) intervention be initiated.
According to the medical record, the assigned RN made a call to the attending surgeon's answering service and received a call back at 01:40 AM from the attending surgeon's partner who gave a telephone order for two nurses to pronounce Patient #1 dead and release the body to the morgue.
During the on-site investigation and review of medical record documentation, it was noted that at the time patient #1 ceased respiratory and cardiac activity, although two physicians (internist) were in the room with the respiratory therapist the pronouncement of death was made by 2 RNs.
Review of the hospital's policy #104 titled "Post Mortem Care and Checklist" also instructs the registered nurse to report clinical signs e.g. time respirations ceased, absence of blood pressure and heart activity to the physician who then declares that the patient has expired and releases the body to the morgue. However, the telephone order received and electronically signed by the physician states "May have two RNs pronounce time of death" .
Based on query to the Maryland State Board of Nursing, it was determined that despite the physician's telephone order for two RNs to pronounce the patient's time of death, only a physician or an Advanced Practice Registered Nurse can pronounce a patient deceased in Maryland. Therefore, even though a telephone order to pronounce Patient #1 deceased was received from the attending physician's partner, the registered nurses were practicing beyond their scope of practice.

Patient #4 is a 61 year old male admitted on July 21, 2013 for an intracranial hemorrhage. On July 22, 2013 Patient #1 underwent an insertion of an Inferior vena cava (IVC) filter for a (DVT) deep venous thrombosis (blood clot). On review of the medical record it was determined that the signature of the primary surgeon was illegible. At the time of the record review neither the surveyor, clinical manager, nor other staff were able to identify the signature.

Based on a review of 8 open records and 6 closed medical records, it was determined that 1 of the 8 opened records contained a telephone order that was not signed by the prescribing physician for four days after the order was given.

Patient #10 was admitted to the hospital on July 19, 2013. Her physician order sheet contained one telephone order (TO) taken by the nurse on July 19, 2013 at 9:40 PM for a now dose of potassium but not signed on July 23, 2013 at 1:20 PM during the survey.