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Based on a review of seven open and nine closed medical records, performed on 4/22/15, it was determined that hospital failed to consistently use professional translators for two of 16 patients. These two patients were unable to receive or contribute meaningful information that would aid in their care due to the use of family members to translate.


Patient No. 1, an elderly inpatient who spoke only Vietnamese, was admitted on 4/19/15. He had a consult by a pulmonary physician on 4/21/15. In the consult note from that date, the pulmonary physician noted that " Brother-in-law at bedside translating. "


Patient No. 3, an inpatient Spanish-speaker, was admitted 4/1/15. During the history and physical examination done on 4/1/15, the admitting physician made the following note: "Most of the history was taken with the help of the daughter who is English Speaking and is at the bedside and helping with translation. "


According to the hospital's policy for using interpreters, Foreign-language Interpretation Services: Services for Patients with Limited-English Proficiency, revised 3/2/13, "the engagement of family members and minors for the purpose of medical interpretation" is prohibited.


The failure to use a certified translator limited each patient ' s right and ability to participate in his or her care, and placed each at risk for injury from treatment decisions based on erroneous information relayed via family members.

Based on seven open and nine closed medical records, performed on 04/22/2015 it was determined that the hospital failed to consistently provided an informed consent to treat for 3 of 16 patients upon arrival to the hospital.
Patient #3, admitted 04/07/2015. - Review of the medical record found no documented consent to treat given upon admission.
Patient #12, was admitted 02/12/2015 and discharged 03/22/2015. Review of the medical record found no documented consent to treat given upon admission.
Patient #16, was admitted 03/11/2015 and discharged 03/23/2015. Review of the medical record found no documented consent to treat given upon admission.

Based on a review of seven open and nine closed medical records on 4/22/15, it was determined that the medical staff failed to complete a history and physical examination (H&P) within 24 hours of admission for one patient (#13) who was inpatient from 3/18/15 to 4/3/15. The first H&P is dated 3/18/15 at 2314. It consists of a statement that the patient had been sent from his dialysis center with low blood pressure along with a brief statement about his medical history. This patient had been in the hospital from 2/15/15 to 3/6/15 for conditions unrelated to his presenting condition, but the physician attached the discharge summary (written by another physician) from this prior admission as the bulk of the H&P. The medical record also contains a complete and accurate H&P done by the admitting physician on 3/24/15, six days after admission.

By including out of date information in the initial H&P, and failing to perform a timely H&P, patient #13 was at risk for injury from treatments predicated on erroneous information.