HospitalInspections.org

Based on facility brochure review, policy review, medical record review, and staff interview, the facility staff failed to effectively communicate with a Limited English Proficiency patient for 1 of 1 patients sampled (Patient #1).

The findings included:

Review of facility brochure, "Patient Rights" dated 03/2020, revealed, "Patient Rights ... 14. A patient who does not speak English or is hearing impaired shall have access, when possible, to a qualified medical interpreter (for foreign language or hearing impairment) at no cost, when necessary and possible ..."

Review of facility policy, "Language Assistance Plan (LAP)" reviewed/revised date 02/2021, revealed, " ...The unit, practice, department, or facility encountering the LEP (Limited English proficiency) individual is responsible for securing a qualified Medical Interpreter and should do so as soon as the need is identified. a. Meaningful Access. (named health system) shall take reasonable steps and exhaust current resources to provide language assistance as quickly as possible. Family members, friends, or any other non-qualified individual may never be used for language assistance .... b. Interpreter Refusal. A patient shall never be offered the option to refuse a qualified Medical Interpreter. Waiving the right to an interpreter is waiving the right to appropriate medical care. The care team must have an effective method of communicating with our patients. A family member or friend is not considered effective communication as he/she is considered an untrained, biased, ad-hoc interpreter."

1. Review of the closed medical record for Patient #1 revealed an 84-year-old male admitted to the facility on 03/09/2021 at 1659. Review of "Preferred Language" revealed, "Arabic". Review of the "Admission H&P (History and Physical)" dated 03/09/2021 at 2300 revealed, "Chief Complaint. Diagnosed with covid 5 days ago. Son reports he has been in and out consciousness all day today. History of Present Illness ...Arabic speaking male with recent diagnosis of COVID-19 ..." Review of "Physician Progress Note" dated 03/10/2021 at 1033 revealed, "Subjective ...He is Arabic speaking male but he is following commands very little and I did not use any interpreter iPad." Review of "SLP (Speech Language Pathologist) Acute Bedside Swallow Study" dated 03/10/2021 at 1623 revealed, "Barriers to Learning: Language barrier, Cognitive deficit Action Plan to Barriers: Interpreter, Cognitive appropriate materials, Teach caregiver..." Review of "Physician Progress Note" dated 03/13/2021 at 1719 revealed, "I saw him this PM and he is awake, alert and oriented. Son was on face time interpreting ..." Review of "Clinical Assessments" dated 03/14/2021 at 2200 revealed, "pt son on FT (facetime)." Review of "Clinical Assessments" dated 03/15/2021 at 1303 revealed, "on Facetime." Review of "PT (Physical Therapy) Acute Evaluation" dated 03/16/2021 at 1923 revealed, "He was drowsy today, minimally verbally interactive and followed simple commands inconsistently ....I feel he is best suited for home discharge with his family given his language barrier and apparent cognitive deficits if his family has the resources to care for him at home." Record review revealed Patient #1 was discharged home with family on 04/09/2021 at 0931. Record review failed to reveal documentation of the usage of a qualified Medical Interpreter to communicate directly with Patient #1.

Interview on 04/28/2021 at 1100 with Case Manager revealed nursing staff identified a language barrier with Patient #1 upon admission. Interview revealed staff utilized family members to communicate with Patient #1.

Interview on 04/28/2021 at 1145 with Nurse Manager revealed the staff attempted to communicate with Patient #1 through the video remote interpreting device. Interview revealed the video remote interpreting device did have Arabic. Interview revealed the video remote interpreting device did not have the specific dialect (particular form of a language which is peculiar to a specific region or social group) of Arabic of Patient #1. Interview revealed staff utilized Patient #1's family members via "facetime" or in person to interpret for Patient #1. Interview revealed no attempts were made to locate a qualified Medical Interpreter that spoke Patient #1's Arabic dialect.

Interview on 04/28/2021 at 1600 with RN #1 revealed Patient #1 understood minimal English. Interview revealed the video remote interpreting device was attempted a few times after Patient #1 was admitted to the unit. Interview revealed the video Medical Interpreters informed the staff that the patient needed a different dialect. Interview revealed staff did not pursue another Medical Interpreter. Interview revealed Patient #1 used "facetime" continuously and various family members interpreted for staff members.

Interview on 04/29/2021 at 1005 with RN #2 revealed Patient #1 had a known language barrier. Interview revealed family members were used regularly for interpreting instead of the facilty approved methods.

Interview on 04/29/2021 at 1050 with Language Access Supervisor revealed the expectation of staff was to identify language barriers, to find, and to use appropriate Medical Interpreters. Interview revealed the staff had access to in person, video, and phone interpreters 24 hours a day, 7 days a week. Interview revealed the expectation of staff was to have exhausted all resources to locate specific dialects for an LEP patient. Interview revealed family members were not to be used to communicate for a patient at all. Interview revealed family members were not appropriate interpreters and should not be used by the staff. Interview revealed the facility policy was not followed.

Based on policy review, medical record review, and interviews the hospital staff failed to provide wound care for 3 of 3 patients. (Patient #2, Patient #24, and Patient #25)

Findings included:

Review of the hospital policy titled "Assessment for Skin Integrity" last revised 05/29/2019 revealed "...V. DOCUMENTATION, Document prevention strategies used every shift and as performed. Document treatment interventions as performed..." Pressure Ulcer Prevention and Treatment Guidelines...Universal Skin Care Practices (All Patients)...If ANY stage pressure ulcer is noted on admission or develops: provide pressure relief reduction to the affected area...Stage I Pressure Ulcer: Measure area of non-blanchable erythema (L x W) in cm (centimeters) and document...Stage II Pressure Ulcer: Measure ulcer length, width, and depth in cm and document. Re-measure at least weekly...For minimally draining ulcers, apply transparent absorbent film and change every 7 days & PRN (as needed) ...For moderately draining ulcers, apply foam dressing and change every 3 days and PRN drainage..."

1. Closed medical record review on 04/27/2021 revealed Patient #2, an 86-year-old female patient admitted to the hospital on 02/20/2021 for Acute Kidney Injury (a condition where the kidneys cannot filter waste from the blood), Dehydration (loss of body fluid caused by illness) and Hypernatremia (high sodium level). Review of the History and Physical dated 02/20/2021 at 0802 by Medical Doctor (MD) #1 revealed Patient #2 had a medical history of poor po (oral) intake, dementia (thinking and social symptoms that interferes with daily functioning), failure to thrive (sign of undernutrition), and Parkinson's disease (a central nervous system disorder that affects movement). Review of the Admission Assessment dated 02/20/2021 at 0400 by Registered Nurse (RN) #1 revealed a Braden Score (uses a score from 9-23 that assesses skin, the lower the score, the higher risk of developing a pressure injury) of 16, and no wounds documented. Review of the Pressure Ulcer Protocol Order dated 02/20/2021 at 0450 revealed a system generated order "Based on charting of Braden Score...Priority Routine. Frequency BID (twice daily)." Review of the Nursing Skin Assessment dated 02/21/2021at 2100 by RN #1 revealed a Braden score of 12, and a left inner leg blister noted, "open to air." Review of the Nursing Skin Assessment dated 02/24/2021 at 2141 by RN #2 revealed a Braden score of 12, "pressure ulcer, foam dressing CDI (clean dry and intact.)" Review of the Nursing Skin Assessment dated 02/24/2021 at 2141 by RN #5 "Left Inner Leg: Abnormality type: Pressure ulcer. Dressing Assessment: Clean, Dry and Intact. Dressing Activity: Applied. Dressing Type: Foam. Pressure Ulcer Stage: 2. Surrounding Tissue: Excoriated. Sound Status: Deteriorating. Associated Pain: None. Wound Odor: None." Review of the Wound Care Consult Note dated 02/25/2021 at 1151 by RN #3 revealed "Integumentary detailed. Wound Assessment Documentation: Yes. Wound Assessment Details: 86-year-old female that I received a computer-generated consult on. This patient has a stage 2 pressure ulcer that is documented in the notes. She is also incontinent I noted in the charting. The pressure injury is being treated with a foam dressing. This is within the protocol of the hospital...WOCN (wound ostomy care nurse) Wound Assessment. Wound Assessment details: WOC Nursing Wound Assessment Details. Incision/Wound: left leg, inner. Most recently charted wound care results by WOC Nurse did not include this wound." Review of Nursing Skin Assessment dated 02/28/2021 at 2000 by RN #6 revealed: "Left Inner Leg: Wound Abnormality Type: Reassess, No change. Abnormality Type: Skin Tear. Dressing Assessment: Clean, Dry and Intact...Incision/Wound/Abnormality (Sacrum) Wound Abnormality Type Activity: Reassess, No Change. Abnormality Type: Erythema." Review of the Nursing Skin Assessment dated 03/01/2021 at 1024 by RN #7 revealed an Assessment of the Left Inner Thigh but did not include an assessment of the Sacrum. Review of the Nursing Skin Assessment dated 03/02/2021 at 2215 by RN #8 revealed: Left Inner Leg and Sacrum assessments with a dressing to the sacrum stating "Pressure Ulcer Stage: 2..." Review of the Nursing Skin Assessment dated 03/10/2021 at 0839 by RN #9 revealed a Braden score of 11, with no wound assessments documented. Review of the Nursing Skin Assessment dated 03/12/2021 at 2000 by RN #10 revealed a Braden score of 14, with no wound assessments documented. Review of the Nursing Skin Assessment dated 03/13/2021 at 1945 by RN #10 revealed a Braden Score of 14, with no wound assessments documented. Review of the Nursing Skin Assessment dated 03/14/2021 at 0830 by RN #11 revealed a Braden Score of 12, with no wound assessments documented. Review of the Nursing Skin Assessments revealed wound dressing changes were documented on 02/24/2021 at 2141, on 03/02/21 at 2215, on 03/11/2021 at 0600, and on 03/11/21 at 1815. Review of Patient #2's wound care revealed there were no wound measurements documented during the wound care. Patient #2 was discharged on 03/14/2021 at 1315 home with Hospice (care focusing on care of terminally ill) care services.

Interview on 04/28/21 at 1010 with the WOCN RN #3 revealed the policy for pressure ulcer stage 2 is to use a foam dressing that should be changed every 3 days. Interview revealed that wound measurements should be documented initially and every 7 days on the nursing flowsheet when completed by the RN. WOCN RN #3 stated, "I measure wounds, unless I have difficulty. I get interrupted and I forget to put things in. I see the RN's using dressing changes per orders..." Interview revealed that if wound dressing orders are not being followed, "the WOCN would communicate that to the Clinical Supervisor and go to the nurse and review the wound orders with them, and would document that conversation with them in the record." Interview revealed that Patient #2's dressing changes "should have been every 3 days." Interview revealed that the hospital policy was not followed for wound measurements and dressing changes.

Interview on 04/28/2021 at 1130 with RN #6 revealed "We are supposed to measure the wounds and wound dressing changes should be completed every 3 days, or more often if soiled. We follow the pressure ulcer protocol." Interview revealed that wound care was reviewed in new hire orientation for nurses, and annually. Interview revealed the hospital policy was not followed.

Interview on 04/28/2021 at 1140 with the Director of Nursing, RN #12 revealed "the expectation for the wound care and dressing changes was to follow the policy and protocol guidelines." Interview revealed the hospital policy and pressure ulcer prevention treatment guidelines for Patient #2 were not followed with wound assessment documentation, measurements and wound dressing changes.

2. Open medical record review of Patient #24 revealed, a 75 year-old male admitted on 04/23/2021 at 2222 with "Cellulitis of bilateral lower leg extremities..." Review of the History and Physical dated 04/23/2021 at 1219 by Medical Doctor (MD) #2 revealed a "redness in left lower leg extremity and left great toe." Review of the Physician Order for WOCN consult was placed by MD #2. Review of the WOCN Consult Orders dated 04/23/2021 at 1407 by RN #3 revealed "Paint left great toe with betadine and cover as needed. Betadine to tip of great toe on the left BID (twice daily at 1000-2200)." Review of the record revealed betadine was applied to left great toe on 04/23/2021 at 1407 by the WOCN, RN #3, on 04/25/2021 at 2123 by RN #12, and on 04/26/2021 at 0800 by RN #13. Review revealed wound care orders for Patient #24 for the left great toe were not followed with betadine application twice daily at 1000 and 2200.

Interview on 04/28/2021 at 1010 with the WOCN RN #3 revealed that the betadine solution for the wound care for Patient #24 was available in the unit stock. Interview revealed that the betadine was to be applied twice daily at 1000 and 2200 to the left great toe, and this would be documented under the nursing skin assessment. Interview revealed the wound care orders for Patient #24 were not followed with betadine application twice daily at 1000 and 2200.

Interview on 04/28/2021 at 1140 with the Director of Nursing, RN #12 revealed "the expectation for the nurse was to follow physician orders for wound care." Interview revealed Patient #24's physician orders for wound care were not followed with betadine application twice daily at 1000 and 2200.

3. Open medical record review of Patient #25 revealed, a 58-year-old female patient admitted on 04/08/2021 at 1159 for acute LLL (left lower leg) cellulitis. Review of the History and Physical dated 04/08/2021 at 1542 by MD #4 revealed Patient #24 had an LLL wound hematoma due to hitting the left leg. Review of the Physician Orders dated 04/09/2021 at 1140 by MD #5 revealed: "Priority Routine. Frequency Daily. Special Instructions: The patients wound next to her hematoma-clean with wound cleanser, apply wound gel and cover with gauze and rolled gauze & tape. Next Dose Dt (date) Tm (time) 04/09/2021 at 1140." Review revealed WOCN RN#3 documented Patient #25's left ankle wound measurements on 04/09/2021 at 0841 as, "length 2.5 cm (centimeters), depth 0.2 cm, width 2.3 cm, surface was 5.8 cm." Review revealed there was no left lateral ankle dressing changes documented on 04/12/2021, 04/13/2021, 04/15/2021, 04/17/2021, 04/20/2021, 04/22/2021. Review revealed Patient #25's wound care orders for the left lateral ankle wound were not followed with daily wound care dressings and documentation.

Interview on 04/28/21 at 1010 with the WOCN RN #3 revealed that Patient #25's wound dressings were to be done daily per the physician order. Interview revealed that if wound dressing orders are not being followed "the WOCN would communicate that to the Clinical Supervisor and go to the nurse and review the wound orders with them, and I would document that conversation with them." Interview revealed that the hospital policy was not followed for wound care and wound dressing changes.

Interview on 04/28/2021 at 1140 with the Director of Nursing, RN #12 revealed "the expectation for the wound care and dressing changes was to follow the policy and protocol guidelines." Interview revealed Patient #25's physician orders for wound care was not followed.

NC00175666, NC00172928, NC00176063, NC00175891