HospitalInspections.org

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Based on observation, record review and interview, the facility failed to ensure that patients were afforded their right to participate in their Plans of Care in two (2) out of two (2) patients identified with a preferred language other than English (Patients #7 and #12).

Findings:

On 03/12/15 at 12:00PM Staff #13 was observed asking Patient #12 for permission to perform blood sugar testing, explaining the testing procedure to the patient and providing the patient with the test results in English. At the completion of the testing, Staff #13 stated to the Surveyor, "This patient doesn't speak English". No family members were observed at the bedside at this time.

Record review on 03/12/15 at 2:00PM revealed that Patient #12 was assessed as having Limited English Proficiency (LEP), a preferred language other than English, and "needing" an Interpreter.

On interview on 03/12/15 at 1:30PM, Patient #12 and their son stated that the patient does not speak or understand any English and that the patient's son speaks a small amount of English, but has limitations as well. They further stated that the patient receives most of the information regarding her condition and treatment from her son. The facility staff have not utilized any interpretive device to communicate with Patient #12 since admission. Patient #12's Physician speaks "very little" of the patient's preferred language and will occasionally utilize some words in the patient's preferred language when communicating with the patient. Patient #12 admits she does not understand most of the information given to her, and will reserve any questions about her care until her son arrives to visit. Patient #12's son states he cannot visit every day.

Both Patient #12 and their son verbalized they are satisfied with the care they have been receiving up to this point, but would prefer if information could be communicated to Patient #12 in the preferred language whenever possible.

Observation on 03/12/15 at 1:45PM revealed the Unit had two (2) available "Stinger" devices for Interpretive Services. These devices are laptops loaded with the Cyracom Interpretation Software and video / audio capability to access a live Interpreter. Staff #11 attempted to demonstrate its use but was unable to access either device due to password difficulties. Staff #13 was called to provide a demonstration of the Stinger and the Cyracom Software. On interview, Staff #13 stated that staff members are taught, and expected to utilize, the Stingers first, then the dual headset phones, when they are unable to communicate with LEP patients. Staff #13 also stated that staff are expected to document, in the patient's Medical Record, the patient's language needs and the acceptance or refusal of Language Assistance Services.

Medical Record review on 03/12/15 at 2:00PM with Staff #11 agreed that there was no evidence of documentation of an Interpreter or Interpretive Device use in the Education Section of Patient #12's Medical Record. Staff #11 was unable to locate any documentation of the use of an Interpreter or Interpretive Device, or the patient's refusal of Language Assistance Services.

On interview on 03/13/15 at 10:00AM, Patient #7 stated he can speak and understand some English, but has LEP. Patient #7's family was present at the bedside, also with LEP. Patient #7 stated that the staff communicate with him in English and the patient recalled pre-surgical staff utilizing a "computer" during his pre-surgical visit to communicate instructions, but since admission, stated no Interpreter or Interpretive Device was used by staff to communicate. When Patient #7 has questions regarding his care or treatment, the patient will ask in English, but it is difficult for him to ensure that the staff understands what is being asked. The patient stated he is aware he is being discharged home today, but added he is not entirely clear if he will be discharged home with his drain, and what he will need to do to care for his surgical site. He also stated he would prefer to receive his Discharge Instructions in his preferred language.

Medical Record review on 03/13/15 at 10:30AM revealed Patient #7 was assessed as having LEP, a preferred language other than English, and as needing an Interpreter during his pre-surgical visit on 03/02/15 at 2:02PM. On admission on 03/11/15 at 8:28AM, the patient was documented as having LEP but no Interpreter "needed". Since admission, no documentation of any patient education or use of Interpreter or Interpretive Device could be found in Patient #7's Medical Record.

This was verified with Staff Members #17, #15 and #3.

The Policy titled Language Assistance, dated 02/2014, states: "When a patient does not speak or understand English, Telephonic and Video Interpretive Services, provided through Cyracom International, are offered to any patient to explain the information required for an informed consent ... this Service should be accessed by trained staff or your Supervisor." This Policy also states Patient Care Staff must document when utilizing the services of an Interpreter in the Medical Record, a Progress Note, etc. The printed name, in this case, the Cyracom Interpreter ID#, should be noted on the Consent Form, Progress Notes, etc.
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Based on record review and interview, the facility failed to ensure Patient Education documentation was complete and consistent with facility procedures for one (1) out of one (1) patients (Patient #7).

Findings:

Review of the Medical Record for Patient #7 on 03/13/15 at 10:30AM with Staff #11 revealed that Patient #7 was admitted on 03/11/15 for Left Leg Surgery on 03/11/15.

Record review revealed there was no Patient Education documentation in Patient #7's Medical Record. Staff #11 was unable to locate any documentation of Patient Education in this Medical Record.

On interview with Staff #11 at 10:30AM, the staff member stated that she does not utilize the Patient Education Record that often. In order to document Patient Education, Staff #11 will, "at times", utilize the comment / free text option in the Daily Assessment Flow Sheets.

An interview with Staff Members #15 and #19 revealed that all Direct Care Staff are expected to utilize the Patient Education Record to document all Patient Education.