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Based on review of medical records and hospital policies it was determined that staff failed to obtain interpreter services for 1 of 1 limited English proficient patients reviewed in the sample

According to the patient's records, upon admission, patient #12 signed a form stating that he wanted use of the language line. However, a progress note of 6/29/2015 stated that a nurse used a family member to obtain admission information. Per hospital policy, family members were not to be used for translation services unless specifically requested by the patient.

The same progress note also stated that an LIP used the language line to obtain information from the patient. Based on this documentation the use of the language line was determined to be inconsistent.

Further, the initial assessment in the ED documented the patient as using English as his preferred language for discussing health care. The same assessment also documented that the patient spoke only Spanish.

The patient's records were contradictory as to whether the patient's communication needs were met.

Review of 16 medical records , observations of registration and interviews of the Emergency Department (ED) staff on 7/9/2015 (am) revealed that patients treated in the ED were not consistently provided Advanced Directive (AD) information and that staff was not knowledgeable of the location of the AD in a patient's electronic medical record (EMR).

At 11:10 AM on 7/9/15 Staff Nurse #3, a registrar, was observed registering information for patient #7. Staff #3 was prompted by the EMR to answer 3 questions regarding advanced directives:
(1) Does the patient have an AD?
(2) Was a copy of the AD placed on file in the medical record?
(3) Was information provided to the patient about making an AD?

Staff #3 was subsequently interviewed by the surveyor. Staff #3 stated that registrars do not provide information to patients about making an an advanced directive unless the patient requests the information.

Interviews with Staff Nurse #1 and Staff Nurse #2 revealed that both nurses could not identify AD information for patients #5, #7, #8, and #9 in the respective medical records. Once the AD information was entered in the medical record by the registrar, the ED nurses did not confirm or review the AD information with the patients.

Failure to provide a patient with information about making an advanced directive and failure of staff to be knowledgeable about patients' advanced directives violated patient rights relative to treatment and care.

A review of 15 patient medical records revealed that the hospital failed to protect the rights of 3 patients (patient #10, #11 and #16) by using an order for restraints on an as needed basis (PRN).

Patient #10, an inpatient on the Behavior Health Unit for depression, was voluntarily admitted on 07/06/2015. Patient #10 had an order for haloperidol, a medication used to treat nervous, emotional and mental conditions. This order was written for 5 mg, every 6 hours, intramuscular injection (IM), as needed, for agitation. Patient #10, also had an order for lorazepam, a medication used to treat anxiety. This order was written for 1 mg, every 6 hours, intramuscular injection (IM), as needed for anxiety/agitation.

Patient #11, an inpatient on the Behavior Health Unit for treatment of delusional behavior, was admitted voluntarily 07/06/2015. Patient #11 had an order for lorazepam, 1 mg, every 6 hours, intramuscular injection (IM), as needed, for anxiety/agitation. Patient #11, also had an order for haloperidol, a medication used to treat nervous, emotional, and mental conditions. This order was written for 5 mg, every 6 hours, intramuscular injection (IM), as needed, for agitation.

Patient #16, an inpatient on the Behavior Health Unit for treatment of bipolar disorder and manic depression, was voluntarily admitted 05/19/2015. Patient #16 had an order for haloperidol, a medication used to treat nervous, emotional and mental conditions. This order was written for 5 mg, every 6 hours, intramuscular injection (IM), as needed, for agitation. Patient #16, also had an order for lorazepam, a medication used to treat anxiety. This order was written for 1 mg, every 6 hours, intramuscular injection (IM), as needed for anxiety/agitation.

Review of 16 medical records and an interview with the Informatics nurse revealed that nursing staff failed to remove bilateral wrist restraints as the earliest possible time for 2 out of 2 patients that were reviewed in wrist restraints.

1. Patient #1 presented to the Emergency Department (ED) on 5/20/2015. The patient was transferred to the observation unit. On 5/21/2015 Patient #1 became increasingly anxious and began to pull on medical tubes and lines. The nurse documented the behavior, contacted the physician to report the change in mental status and obtained a sitter for the patient. The patient continued pulling on medical lines and tubes and attempted to get out of bed even with redirection by the sitter. Soft wrist restraints were ordered and placed on the patient on 5/22/2015. The patient's sitter documented the restraints were initiated on 5/22/2015 at 4:00 AM. The electronic medical record (EMR) noted that the restraints were initiated at 5:09 AM on 5/22/2015. Patient #1's nurse wrote a summary note stating "Assumed care of patient at change of shift (7 AM). Patient was sleeping with BUE (bilateral upper extremity ) restraints in place and a 1:1 sitter was at bedside. At 8:30 AM patient agitated trying to climb out of bed. Reinforced restraints. PA (physician assistant) made aware. At 8:52 AM patient medicated with Ativan 0.5mg IV per order. At 9:30 AM patient calm, sleeping but arousable. At 5:30 PM cardiology seen patient. Shallow breathing noted. Applied 02 (oxygen) at 2 liters nasal cannula (oxygen saturations 96%). At 5:40 PM patient more alert and awake. Patient able to eat dinner. Patient calm follows commands. Released restraints at this time. Wife at bedside." Nursing documentation, as well as the sitter documentation, indicated that the patient was calm. However the restraints remained in place for an additional 8 hours until 5:40 PM.

2. A review of Patient #16's medical record revealed that he was in bilateral wrist restraints for violent behavior on 6/1/2015 while on the medical/surgical unit. Assessments were conducted every 15 minutes. Patient #16 was asleep with restraints on from 8:30 AM to 9:15 am, from 12:00 PM to 1:00 PM and from 4:30 PM to 5:45 PM. Staff failed to remove Patient #16's restraints at the earliest possible time.

Failure to remove restraints at the earliest possible time had the potential to cause unnecessary mental and physical harm to the patients.

During an observational tour of the Emergency Department with the department chairman and director on 7/9/2015, single dose 10 milliliter vials of injectable medication (Bupivacaine 0.5% and Lidocaine 2%) were discovered in the Pod D medication storage area cabinet. Both vials were opened and were half empty. The ED chairman confirmed this finding and stated that he was not aware that staff had been returning the used single dose vials of remaining injectable medication to the cabinet. He also stated that single dose vials of remaining medication were to be discarded.

The hospital medication policy which became effective in 4/2014 was reviewed and stated that injectable vials labeled as "single use" or "preservative free" may never be used to withdraw multiple doses for patient administration.

Failure to dispose of single dose vials of injectable medication which had been partially used has the potential to cause harm and infection. These medications typically lack antimicrobial preservatives and can become contaminated. As a result the medications can potentially serve as a source of infection when they are used inappropriately.

Review of 16 medical records, an interview with the Director of Case Management, an interview with a patient's Social Worker and a review of the hospital's discharge planning policy revealed that the hospital staff failed to document a discharge planning assessment/evaluation for one patient (#1) as evidenced by:

Patient #1 was admitted on 5/20/2015. The patient's discharge risk screening was completed on admission to the medical/surgical unit by the admitting nurse. This screening identified the need for a consult by a Social Worker to evaluate the patient's post hospital placement.

Patient #1 was discharged to a Skilled Nursing Facility (SNF) on 5/29/2015. The discharge planning assessment/evaluation addressing specific needs of the patient which was to be completed by the Case Manager or Social Worker, was not found in the patient's medical record. An interview with the Social Worker and the Director of Case Management on 7/10/2015 at 11:20 AM confirmed the finding that the patient had not received a discharge planning assessment or evaluation by the discharge planning team.


According to the hospital's Discharge Planning Policy, the Case Management Department is responsible for completing the discharge planning assessment within 96 hours (4 days) of discharge. During an interview conducted on 7/10/2015 at 7:30 AM, the Director of Case Management stated discharge planning assessments can be difficult to complete within this timeframe, and that she, along with her staff, were reviewing the time that assessments are being completed in order to improve the discharge process.


Failure to complete the discharge assessment for each patient may result in not addressing specific needs of the patient.

A review of 16 medical records and interviews with staff revealed that the hospital failed to reassess a patient's discharge plan when her needs changed as evidenced by:

Patient #16 was voluntarily admitted from another healthcare facility to the Behavior Health Unit on 5/19/2015 for treatment of bipolar disorder and manic depression. Arrangements were made for patient #16 to be discharged back to that facility after treatment. The patient was scheduled to be discharged on 5/28/2015 to the facility, but she refused to go. The patient was considered to be at baseline, and she was her own guardian. By this time the needs of the patient had changed but her discharge plan remained unchanged.

On 5/29/2015 a caregiver from the facility came for the patient. Again she refused to go. The hospital then offered to send the patient to a shelter. Patient #16 was discharged by taxi to a shelter. Based on her needs for medication compliance and care, this was an inappropriate discharge plan for patient #16. The patient needed more resources after discharge that a shelter was unable to provide.

On 5/29/2015 the shelter send patient #16 to the ED due to behavioral problems. The patient was assessed and discharged. On 5/30/2015 patient #16 was presented to the ED after EMS found her on the facility property. The patient was assessed and discharged. On 5/31/2015 the patient was found on the hospital property trying to get into a moving vehicle. During this ED visit , the patient had seizures and was medically admitted.

By failing to reassess patient #16's needs and failing to modify her discharge plan the hospital put the patient's health at risk. As a result patient #16 was brought to the ED three times within 2 days after discharge of the initial discharge.

Observation of care rounds on 7/10/2015 at 9:25 AM for one patient (patient #2) and review of 16 medical records revealed that the hospital failed to disclose financial interest of the skilled nursing facilities (SNF) on the lists of potential placements that are provided to patients.

During an interview and medical record review with the director of case management the morning of 7/10/2015, it was revealed that the hospital does not maintain the list of potential SNFs that are provided to patients in the electronic medical record (EMR).

On 7/10/2015 at 10:45 AM a Social Worker was observed providing a written list of possible SNF placements to patient #2. No verbal information about financial interests between the hospital and the SNF was disclosed to the patient. During the interview with the Director of Case Management the morning of 7/10/2015 it was revealed that one SNF on the list provided to patient #2 did have an affiliation with the hospital and confirmed that no disclosure of financial interest was provided to patient #2.

There was no documentation in patients' medical records and no observed communication with patient #2 identifying information on SNF lists supplied to patients that the hospital disclosed interests.