HospitalInspections.org

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined the hospital was not in compliance with applicable Federal laws related to the health and safety of patients for one of one patient in five medical records for five different encounters (MR1, MR2, MR3, MR4, MR5).

Findings include:


Review of 42 U.S. Code §12182-"Prohibition of discrimination by public accommodations" revealed, "(a) General rule No individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, ... of any place of public accommodation ..."

Review of "Title 28, Chapter 1 Part 35-Nondiscrimination on the Basis of Disability in State and Local Government Services 35.160 General revealed, "(b)(1) A public entity shall furnish appropriate auxiliary aids and services where necessary to afford individuals with disabilities, including ... members of the public, an equal opportunity to participate in, and enjoy the benefits of, a service, program, or activity of a public entity. (2) The type of auxiliary aid or service necessary to ensure effective communication will vary in accordance with the method of communication used by the individual; the nature, length, and complexity of the communication involved; and the context in which the communication is taking place. In determining what types of auxiliary aids and services are necessary, a public entity shall give primary consideration to the requests of individuals with disabilities. In order to be effective, auxiliary aids and services must be provided in accessible formats, in a timely manner, and in such a way as to protect the privacy and independence of the individual with a disability. (c)(1) A public entity shall not require an individual with a disability to bring another individual to interpret for him or her. (2) A public entity shall not rely on an adult accompanying an individual with a disability to interpret or facilitate communication except-- (i) In an emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no interpreter available; or (ii) Where the individual with a disability specifically requests that the accompanying adult interpreter facilitate communication, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances..."

Review of the hospital's Administrative Policy #92 "Provisions for Assistance in Communications" revised September 2014, revealed, "The following provisions are made for patients needing assistance in communication: ... 2. Deaf Interpreting Services are available via a Video Remote Conferencing using designated IPADs available for sign out from Security... 5. Pictograms are available in the Emergency Care Center for patients who use American Sign Language..."

1. Review of MR1, MR2, MR3, MR4, and MR5 revealed the adult patient was deaf, mentally handicapped, autistic, and unable to speak intelligible words. There was no documentation that the patient, who was in the Emergency Care Center six to seven hours each visit, was offered an effective means of communication other than the person(s) accompanying him/her, or that the patient specifically requested the person(s) accompanying him/her to assist with communication, and that the person(s) accompanying him/or her agreed to provide assistance with the communication.

2. Interview on March 6, 2015, at 1:35 PM with EMP1 confirmed that there was no documentation in the medical records regarding how information was effectively communicated with the patient or that the patient was offered any means of communication listed in the hospital's policy.

Based on review of facility documents, medical records (MR), and staff interviews (EMP), the facility failed to provide the patient the right to participate in the development and implementation of his or her plan of care for one patient in five of five medical records (MR1, MR2, MR3, MR4, and MR5).

Findings include:

Review of Administrative Policy No: 35 "Legal Consent Forms" reviewed April 2013, revealed, "I. General Consent Form (AD-4) provides personal coverage for persons who have legitimate reasons for touching or ministering to the patient and protects both he Health System and physician. B. It is mandatory that the General Consent Form be signed for every patient admitted to the Health System. The consent permits the Health System and its employees who have legitimate reasons for touching or ministering to the patient to provide the care requested by the physician... III. Who may consent A. Whenever possible, the patient should sign the General Consent or Informed Consents ... C. Health Care Agents and Representatives If a patient is incompetent or otherwise unable to consent, the patient's guardian, agent, health care agent, or health care representative must sign the General or Informed Consent form. 1. An Agent or Health Care Agent is an individual designated by the patient in a power of attorney or an advance health care directive. The patient's power of attorney or advance directive should be examined to determine the authority of the agent to consent. 2. A Health Care Representative is an individual authorized to make healthcare decisions for a principal. The Health Care Representative may be, in descending order of priority: i. The spouse ... ii. An adult child iii. A parent ... vi. An adult who has knowledge of the patient's preferences and values, including, but not limited to, religious and moral beliefs, to assess how the patient would make health care decisions..."

Review of "Title 28, Chapter 1 Part 35-Nondiscrimination on the Basis of Disability in State and Local Government Services 35.160 General revealed, "(b)(1) A public entity shall furnish appropriate auxiliary aids and services where necessary to afford individuals with disabilities, including ... members of the public, an equal opportunity to participate in, and enjoy the benefits of, a service, program, or activity of a public entity. (2) The type of auxiliary aid or service necessary to ensure effective communication will vary in accordance with the method of communication used by the individual; the nature, length, and complexity of the communication involved; and the context in which the communication is taking place. In determining what types of auxiliary aids and services are necessary, a public entity shall give primary consideration to the requests of individuals with disabilities. In order to be effective, auxiliary aids and services must be provided in accessible formats, in a timely manner, and in such a way as to protect the privacy and independence of the individual with a disability. (c)(1) A public entity shall not require an individual with a disability to bring another individual to interpret for him or her. (2) A public entity shall not rely on an adult accompanying an individual with a disability to interpret or facilitate communication except-- (i) In an emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no interpreter available; or (ii) Where the individual with a disability specifically requests that the accompanying adult interpreter facilitate communication, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances..."


1. Review of MR1 revealed a four page "Inpatient/Outpatient Condition of Admission and Consent to Medical Treatment-PA" revised February 2014, with illegible writing on page 2, 3, and 4, which was identified as the patient's signature. The form included permission for the assignment of insurance benefits, general consent for tests, treatment, photos, video, and services. On page three above one of the signatures was a statement, "The undersigned certifies that s/he has read the foregoing, understands it, accepts its terms, has received a copy of it and is the patient or is duly authorized by the patient as their agent to execute the above." Documentation in the medical record revealed the patient was deaf, had Mental Retardation, and was exhibiting behaviors at the time of admission. There was no documentation how the information was communicated with the patient prior to the patient "signing" the form. Review of information from the patient's group home listed a person to contact for an emergency as someone other than the person listed on the hospital records.

2. Review of MR2 revealed the patient was deaf and had Mental Retardation. The "Inpatient/Outpatient Condition of Admission and Consent to Medical Treatment-PA" revised February 2014, was marked that the patient was unable to sign. There was no documentation of who the patient wanted to designate as a representative or how the patient was communicated his rights. Hospital documentation of a contact person listed a person from the patient's group home. Review of documentation from the patient's group home listed a different contact person for emergencies.

3. Review of MR3 revealed the patient was deaf and had Mental Retardation. Documentation revealed that the patient normally communicated with sign language, but only had a limited capability of doing so. There was no documentation that the facility attempted to communicate with the patient other than through the person(s) that brought him/her in to the facility. There also was no documentation that any other means of communication with the patient was attempted.

4. Review of MR4 revealed the patient was deaf, autistic, and had Mental Retardation. Documentation by the physician revealed that signs and symptoms of concern were discussed with "the caretaker". There was no documentation of the patient requested the "caretaker" to interpret for him/her, that the caretaker accepted the request, or that any other means of effective communication were provided to the patient.

5. Review of MR5 revealed the patient was deaf, autistic, and had Mental Retardation. Documentation revealed that the patient was not able to speak or hear "but has staff with [him/her] for help with communication. There was no documentation that the patient requested staff to interpret for him/her, that the staff accepted the request, or that any other means of effective communication were provided to the patient.

6. Interview on March 5, 2015, at approximately 11:35 AM with EMP1 confirmed the the findings for MR1.

7. Interview on March 6, 2015, at approximately 12:15 PM with OTH1, OTH2, OTH3, OTH4, and OTH5 revealed that the patient had limited capability to read lips, communicate with pictures, and use some sign language.

8. Review of information from the group home where the patient resided revealed the emergency contact person was a different name that what appeared in the hospital records as a contact person.

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined the facility failed to maintain a medical record that contained sufficient information to monitor the patient's condition and document the results of treatment accurately in five of six medical records (MR1, MR2, MR3, MR4, and MR6). MR 1-4 are the same patient.

Findings include:

Review of Clinical Information Services Policy #4 "Medical Record Content Required Patient-Specific Data and information" reviewed September 2013, revealed, "2. A complete medical record shall be defined as one that contains sufficient information to identify the patient, support the diagnosis, justify the treatment and document the course, results, and response to medications and services in an accurate and timely manner, and facilitate the patient's continuity of care among health care providers. 3. Each medical record shall contain at least the following: ... a. Patient's name, address ... b. Legal status, for mental health services... j. Evidence of informed consent for procedures and treatments as required by hospital policy... n. Progress notes made by the medical staff and other authorized individuals. o. All reassessments, when needed. p. Clinical observations. q. Response to care provided... 5. The medical records of patients having emergency care also contain: ... d. final disposition e. condition at discharge..."

1. Review of MR1 (09/2014 encounter) revealed conflicting information regarding the patient's residential address, and a lack of documentation regarding when, how, and if communication occurred with the patient prior to him/her signing a consent and during the course of care, behaviors exhibited in the Emergency Care Center (ECC), a complete nursing assessment noting communication barriers, usual mode of communication, patient behaviors during time in the ECC, response to medications, and discharge time and condition at time of discharge. Information from Security, who monitored the patient during the ECC stay was not included in the medical record.

This adult patient presented to the hospital (ECC) with aggressive behavior including punching him/her-self in the face. The general consent for treatment contained the "signature of the patient" after a statement that "The undersigned certifies that she/he has read the foregoing, understands it, accepts its terms, has received a copy of it and is the patient or is duly authorized by the patient as their agent to execute the above." There was no documentation how this information was effectively communicated to the patient. Review of the registration information listing the patient's address was a different address than the address listed on the Clinical Discharge Summary. Review of the triage note revealed the preferred language was English, but failed to reveal the patient was deaf, mute, mentally challenged, and had autism. There was no documentation of who, specifically, or how many "staff" accompanied the patient, or how to effectively communicate with the patient. Documentation by the physician noted that the patient resided in a group home and "staff" related the patient had been "a little bit more aggressive." The physician also noted that the patient "does seem to answer questions appropriately to staff with signing." The patient was given oral medication to calm down the aggressive behavior. An additional dose of medication was given 45 minutes before the patient left the facility. There was no documentation of a nurse assessing the effectiveness of the medications that were administered. A behavioral health liaison noted at 7:57 PM, "In ECC pt exhibited behaviors of head banging and had to be stopped for [sic] doing this several times. pt was given Zyprexa and Ativan, with little effect..." The physician noted that the patient was discharged with the condition of the patient listed as improved. Nursing noted that the patient was discharged at 8:23 PM. The registration form noted the discharge time was 11:59 PM. The discharge disposition noted the discharge was to another type of facility without identifying the facility as a group home.

Review of a security report "ECC Patient Monitoring Form" for this patient (MR1) on this date revealed documentation by security regarding patient behaviors during the time the patient was in the Emergency Care Center. Security documentation showed the patient was combative and very loud at 8:10 PM, the nurse administered oral medication for the aggressive behavior at 8:15 PM and the nurse discharged the patient at 8:17 PM. The patient left the ECC at 9:00 PM due to delay with transport.

Interview on March 5, 2015, at 1:35 PM with EMP1 confirmed there was no documentation by ECC nursing staff describing how the patient acted, how or with whom communications were made, or how the patient responded to medications that were administered to the patient. EMP1 further confirmed that documentation by security did not become part of the permanent record.

2. Review of MR2 (08/2013 encounter) revealed conflicting information regarding the patient's address, lack of documentation of the explanation of care to the patient, lack of identification of the mode of communication, permanent issues such as being mental retardation, deafness and muteness listed as being resolved, results of care, and response to medication. There was no documentation that the general consent was explained to the patient, how this was done, or the patient's ability to understand communications.

This adult patient presented to the ECC via ambulance for physically and sexually aggressive behaviors at 6:15 PM. The address for the patient listed on the Registration sheet did not match the address on the Clinical Discharge Summary. The general consent was marked that the patient was unable to sign. There was no documentation that the information was provided to the patient or caregivers. The ECC physician note at 10:06 PM revealed, "The patient ... has a history of severe autism... [He/she] basically does not communicate verbally... Upon arrival [he/she] started acting out again and is becoming increasingly escalated ... The patient is nonverbal, so I am unable to assess suicidal or homicidal ideation..." Documentation by the behavioral health liaison revealed the patient was non-verbal, deaf, autistic, and mentally challenged. Assessment by an ECC nurse noted that the patient had a past history of "Mental Retardation ... Life Cycle Status: Resolved ... Central Deafness ... Life Cycle Status: Resolved... Muteness ... Life cycle Status: Resolved..." There was no documentation of offering other methods of effective communication including provision of an interpreter or use of pictograms. Nursing documented at 10:30 PM (4 hours and 15 minutes after the patient arrived) that the patient communicated with [group home] staff via sign language. Review of additional documentation by the physician noted that "A psychiatric evaluation is not really further possible secondary to [his/her] agitation and [his/her] inability to communicate verbally..." and, "I have completed an involuntary hospitalization form and [he/she] has been accepted for transfer..." No copy of the 302 form (Involuntary admission form) was found in the medical record.

Interview with EMP1 on March 10, 2015, at 3:30 PM revealed, "302 papers would have been sent with the patient- we did not keep copies and do not now. We have no reason to keep them if it is documented that the forms were completed- The receiving facility would not have accepted patient without them and we could not have transported without them."

3. Review of MR3 (09/2013 encounter) revealed conflicting documentation about the chief complaint for the patient, mode of arrival, lack of authentication of a handwritten document, conflicting time of being released from one hospital and arrival time at this hospital, and lack of documentation of effective communication with the patient.

This patient presented to the ECC at 3:27 PM by ambulance for a rectal bleeding according to the documentation on the ambulance trip sheet. According to documentation by the ECC physician, the patient was there for a psychiatric evaluation and marked the chief complaint as "302". Review of the triage nurse note revealed the patient arrived by private car. The general consent for treatment was signed by two people other than the patient with no explanation of who the people were or why they were signing for the patient. The address on the registration form did not match the address on the Clinical Discharge Summary or the Emergency Care Center Record-Face Sheet. A handwritten note with no author identified revealed the patient resided at a group home and was just released from another psychiatric facility the same day at "15:30" (3:30 PM), three minutes after they were registered at this facility. The patient had been in the other facility for 21 days. The facilities are approximately 74 miles apart. The note also included that on the ride back, the patient was trying to grab the steering wheel. Documentation by the ECC physician also noted that the patient grabbed the steering wheel multiple times, trying to cause accidents while driving back to the group home. "The patient ... has profound mental retardation and limited communication abilities. [He/she] is deaf, normally communicates through sign language and only has a limited ability to do so with that..." Review of the behavioral health liaison documentation revealed, "Patient initially brought to ER due to aggressive behavior toward [group home] staff and running into traffic in front of the group home. Per staff he was grabbing the steering wheels of individuals if their car window were open..." There was no documentation that an effective method of communication according to facility policy was offered to the patient or attempted. The patient was transferred to another facility in the town 70+ miles away by ambulance for further evaluation of the medical problem.

Review of documentation from the patient's group home revealed neither of the signatures on the consent were the name of the person listed to be notified in an emergency.

4. Review of MR4 (12/2013 encounter) revealed conflicting information about the patient's address, lack of explanation of why someone other than the patient signed the general consent form, lack of documentation of effective communication with the patient, and lack of documentation how the patient normally communicated with staff.

This patient was brought to the ECC at 5:55 PM by ambulance after a choking episode. The registration sheet with the patient's address did not match the address on the Emergency Care Center Record-Face Sheet and the Clinical Discharge Summary. The general consent was signed by at least one support person from a group home. There was no documentation of who explained the information on the consent , to whom it was explained, or how it was communicated. The area for language on the Clinical Discharge Summary was marked "English." The nursing assessment at 6:36 PM revealed "Best Verbal Response Glasgow: Inappropriate words Best Motor Response Glasgow: Obeys simple commands..." The physician documented that "History is limited due to patient being deaf and autistic. There was not documentation of how communication with the patient was achieved.

5. Review of MR6 revealed an address on the Registration sheet that did not match the address on the Clinical Discharge Summary.

6. Interview on March 10, 2015, at approximately 3:15 PM with EMP1 confirmed the conflicting addresses on medical records and stated the reason for it was unknown.