HospitalInspections.org

Based on record review and interview, the facility failed to ensure patient's rights requirements were exercised, and met, as evidenced by the failure to utilize language translation services to communicate with patient in her declared preferred/native language (Patient ID #1).

Findings included:

HHSC Intake by complainant for patient ID #1 received in email on 7/8/2023 stated "he (the doctor) knew (complainant) did not speak English, he never approached with a translator."

Record Review of Medical Record for patient ID #1 revealed "Notice of Language Assistance Services" form which stated "Would language assistance services help us communicate meaningfully with you?" The box "Yes" was electronically checked. Patient ID#1 had signed the form.

Record Review of Medical Record for patient ID #1:
a) revealed discharge instruction signature page which was unsigned by patient or healthcare team member. This form had the statement "The above-named patient and/or guardian has received the following: Patient Visit Report, Discharge Medication Report, Patient Instructions: Abdominal Pain, Liver Biopsy, Liver Panel, Ondansetron Oral Tablet, Treating Cirrhosis, Vomiting Ch. Signature Disclaimer: Please make sure you have read through this information before signing." It was confirmed on 8/14/2023 at 2:30 pm by Clinical Informatics Staff ID #73 that the instructions had been printed from the electronic Krames education portal in Spanish.
b) The Discharge Summary for patient failed to mention the use of translation services for communicating discharge needs, care, follow-up or signs and symptoms to return to care. There was no use of bedside translator or translator ID# listed in the physician or nursing documentation.

Record Review of facility policy "Patient Rights and Responsibilities", last approved 08/2023, stated "Decision Making and Notification: Access to Services. To receive as soon as possible, the free services of a translator and/or interpreter, telecommunication devices, and any other necessary services or devices to facilitate communication between the patient and the hospital's health care personnel ..."

Record Review of facility policy "Accommodating Persons with Limited English Proficiency (LEP)", last approved 07/2023, stated "Kingwood Campus: The primary vendor used for language assistance services is CulturaLink which is available 24 hours 7 days a week. CulturaLink can be accessed via an iMobile device or by calling 888-444-0688. When prompted, enter your 7 digit access code."

Interview with Clinical Informatics Staff ID #73 on 8/14/2023 at 2:35 pm, she confirmed that when patient materials were printed in Spanish this would be visible and verifiable in the electronic medical record. She was able to demonstrate liver biopsy patient education, in the Krames system which, was utilized by clinical staff for patient education material, would display and print in Spanish, if requested in the system.

Interview with Nursing Director Staff ID #63 on 8/14/2023 at 1:30 pm, she confirmed that staff should utilize an "iMobile" device which provided language assistance services 24/7. She stated that the device connected you to a video or audio translator who provides their "ID number", which should then be documented in the medical record.

Based on interview and record review, the facility failed to ensure that two (2) of two (2) radiology procedural patients were provided sufficient instruction to ensure a safe discharge (Patient ID#s 3 and 23).

Findings include:

Record review of facility policy titled "Admission and discharge: Procedures" dated 07/2020 showed the following information:

Discharge Guidelines:

A. Each patient being discharged will be provided appropriate discharge instructions regarding any follow up care, which may be required with documentation of special teaching and provisions of these instructions in the discharge assessment/instruction module.

Procedure:

5. Complete discharge instruction including vital signs monitoring instructions, follow up instructions, new prescriptions written by physician, food/drug information pamphlet provided (if applicable), and any other relevant information.
C. Print any pertinent patient discharge education. Give the education to the patient, have the patient or person receiving the education sign the front page. Place the signed page in the patient's chart.

Record review of Patient ID # 3's clinical record revealed she had a 10.2 fr. left pelvic drain placed 6/12/2023.
Discharge Summary dated 6/15/2023 states: ID recommended IV antibiotics at home, and this was set up for patient at home. Surgery will follow up with her as an outpatient for drain management.
She was discharged home from the facility with no documentation of verbal or written discharge instructions for home IV antibiotics or catheter/drain care.

Interview with Case manager (ID #71) on 8/14/2023 at 10:25 AM stated that it is the bedside nurse's responsibility to provide discharge instructions for patients prior to discharge.

Record review of Patient ID #23's medical record revealed he had a liver biopsy performed 6/14/2023. He was discharged home from the facility with no documentation of verbal or written discharge instructions for liver biopsy.

Interview with Director of clinical informatics (ID# 73) on 8/14/2023 at 1:38 PM confirmed the above findings and that the instructions are available for use/print in the hospital's Krames system.

Based on record review and interview the facility failed to ensure discharge planning evaluations were performed in two (2) of six (6) patients (ID#s 18 and 19).

Findings include:

Record review of facility policy titled "Discharge Planning" dated 06/2021 showed the following information:

Policy:
It will be the policy of the case management department to initiate and assist the patient/family and physician with a safe and appropriate discharge within one business day of admission.

Procedure:
A. Patient Assessment
1. Within one business day to the facility, the patient's primary nurse and CM/SW complete an initial screening evaluation of the patient for discharge needs.


Review of medical record for patient (ID # 18) on 8/14/23 at 10:23 AM showed admission date of 8/11/23 with no discharge planning evaluation (DPE) completed.

Review of medical record for patient (ID # 18) on 8/14/23 at 10:27 AM showed admission date of 8/12/23 with no discharge planning evaluation (DPE) completed.

Interview with RN Case Manager (ID# 71) on 8/14/23 at 1045 AM, confirmed the above findings. She stated that there is only one (1) person scheduled on Saturday and Sundays to perform the DPE.

Based on interview and record review, the facility failed to ensure post-acute services were referred and facilitated for one (1) of one (1) patient (ID # 3).

Findings include:

Review of medical record for patient (ID# 3) showed the following:
Admission date of 6/8/2023.

Discharge Summary dated 6/15/2023 states: ID recommended IV antibiotics at home, and this was set up for patient at home. Surgery will follow up with her as an outpatient for drain management.

Case management report shows the discharge planning evaluation was performed 6/9/2023 with no needs identified. There were no additional case management notes.

Interview with Director of Case Management (ID # 74) on 8/14/2023 at 1:00 PM stated that there was no order written for patient (ID#3). She stated that the doctor sometimes will set up IV antibiotics to be done in his office and provides the information to the patient. She went on to say that it should be reflected in the documentation.