HospitalInspections.org

Based on a review of 7 open and 4 closed medical records, it was determined the hospital failed to provide 2 Medicare recipients with the standardized notice, "An Important Message from Medicare," (IMM) within the appropriate time frame.

A review of patient #8's closed medical record revealed no evidence or documentation of a second IMM given before discharge after a stay of 7 days.

On review of a closed medical record for patient #9, no initial IMM was found though the patient had been admitted for greater than 2 days.

Based on review of hospital policy and 7 open and 4 closed medical records, it was determined the hospital failed to uphold the patients' right to be informed and participate in care and treatment by not providing adequate interpreter services for 2 out of 11 patients (pt. #1 and pt. #2).

Per hospital policy titled "Communications With Persons With Limited English Proficiency" Reviewed 01/2018) under the definitions section, it states "Individual with Limited English proficiency means an individual whose primary language for communication is not English and who has a limited ability to read, write, speak, or understand English." Under the policy section "Interpreter Services" it states "A qualified interpreter will be offered, free of charge, to individuals with Limited English Proficiency when the service is a reasonable step to provide meaningful access for that individual. (The hospital) will not require an individual with Limited English Proficient to provide his or her own interpreter."

Patient #1 (pt. #1) was a 65+ year old Hispanic patient who presented to the hospital via Emergency Medical Services due to altered mental status. Per "Communication Assessment Form" dated the first day of pt. #1's admission a check box was selected stating "Patient's condition does not allow and/or the companion is not available to complete the Communication Assessment Form." Pt. #1 was not alert or oriented and was unable to give their name at time of admission to the CCC (Critical Care Center). Pt. #1 was found to have hypothermia and was in acute respiratory failure. On day two of admission, pt. #1 was intubated and sedated. Pt. #1 was extubated on day 18 of admission.

Per provider note on the 19th day of admission, pt. #1 was "alert and oriented." Per Physical Therapy evaluation note that same day, it was documented pt. #1 "Requires language interpretation but pt understands limited English." In that same note, the Physical Therapist also documented patient was "alert and oriented to person." "(Speech Language Pathologist (SLP)) was present and able to provide interpretation." The surveyor confirmed that the SLP was not designated as a qualified bilingual staff by the hospital. Further, no record provision was found which delegated discussion of pt. #1's care and treatment to the SLP. This was within the scope of Pt. #1's physician.

Per "Interpretive Service Log" an entry on the 23rd day of pt. #1's admission was the only indication in the record that a qualified interpreter was ever utilized to communicate with pt. #1. On this same day, a surveyor spoke with the patient using a hospital Spanish interpreter. Pt. #1 was able to state they preferred to speak in Spanish.

Pt. #2 was a 65+ year old patient who presented to the emergency department due to weakness and altered mental status. Pt. #2 was from an African country and recently came to the United States. Pt. #2 was admitted to the Critical Care Center (CCC) for workup of ascending paralysis. There were multiple instances found in the chart indicating patient required interpreter services. Per the emergency providers note at 01:56, it was documented "Per friend at bedside who is translating for her ...)" Per Critical Care Progress Note by resident on 1st day of admission at 18:30 "(Pt. #2) does not speak English." In the same note it was documented "Pt was not following commands when asked to hold her leg in the air. Unsure if language barrier was to blame." Per attending note on same day at 20:23 they listed under the pt. #2's problem list "English language deficiency." Per Critical Care Progress Note on the 3rd day of admission, the provider documented patient "denies pain able to express (themselves) except for the language barrier." Per Neurology Progress Note on this same day at 15:12 it was documented "Pt has limited understanding of English. Communicating mostly through (family member)." The above interactions did not mention the use of a qualified interpreter being used. There were two instances in the record where interpreter services where mentioned, however they were not documented on the "Interpretive Service Log."

In summary, the hospital failed to obtain interpretive services for numerous interactions involving pt. #1 and pt. #2 and in doing so, failed to provide pt. #1 and #2 an understanding of their treatment during their hospital stay as well as allowing them to be active participants in their care due to ongoing language barriers.

Based on a review of 7 open and 4 closed patient records, it was determined that due to a lack of interpreter services, the hospital failed to obtain translation services to 1) determine whether pt. #1 and pt. #2 retained decision making capacity; and 2) give informed consent for procedures.

Please refer to tag A-0130. Further review of pt #1's record revealed on admission day two, a consent titled "Informed Consent and Agreement to HIV testing." The consent was signed by the physician and one other hospital staff but not by pt. #1. However, the testing was completed. Per Critical Care Progress Note on this day, pt. #1 was "Alert, Oriented, Follows commands." However, there was no indication that interpretive services were obtained or attempted by which to obtain a consent from pt. #1. Therefore, the hospital failed to honor the patient's right to make informed decisions about pt. #1's care.

See Tag A-0130 regarding pt. #2. A consent was found in pt #2's chart titled "Consent for Operations and Other Procedures" for "Central Venous Catheter" that was dated on pt #2's second day of admission. The consent was signed by a "family friend." There was no indication that the hospital attempted to obtain interpreter services by which to give pt. #2 informed consent, or to determine if pt. #2 had capacity to make consent. Further, while the hospital failed to determine capacity status, the hospital also could not determine an appropriate surrogate prior to obtaining consent from a "family friend."

Another consent titled "Consent for Operations and Other Procedures" was found for "Lumbar Puncture" dated on the 4th day of pt. #2's admission. While this consent appeared to have been signed by pt. #2, there was no indication in the record that interpreter services were used when explaining the procedure, including the risks and benefits, or obtaining this consent. As mentioned in Tag A-130, there were multiple instances in the chart that indicated patient required interpretive services.

In summary, the hospital failed to provide patient #1 and #2's right to make informed decisions when it failed to obtain the necessary interpretive services to determine the capacity to make health care decisions, and give informed consent for procedures prior to referring to a surrogate decision maker.

Based on a review of the hospital "Use of Restraints" policy (reviewed 10/2018) and two restraint/seclusion events, it was determined that for patient #5 (pt. #5), release from seclusion at the earliest possible time may have been delayed due to inappropriate assessment elements and scant behavioral documentation.

Review of hospital policy "Use of Restraint" revealed in part, "Seclusion: ...This may be used only for the management of violent or self-destructive behavior ..."

Pt. #5 was secluded at 1345 due to aggressive behaviors. No documentation was found which informed pt. #5 of the criterion for release from seclusion. However, documentation in pt. #5's record revealed multiple RN references to pt. #5 being unable to "contract for safety." This was inappropriately used to justify continued seclusion. Further, this demonstrated that had pt. #5 met the behavioral goal of cessation of imminently dangerous behavior, staff could have continued to justify seclusion because pt. #5 did not also state a contract for safety.

Hospital Restraint policy continued, "...e. Assessment and monitoring by the RN every hour, and the PCT (psychiatric care tech) every fifteen (15) minutes, of the following, at a minimum: i. Behavior ..."

The medical record indicated that pt. #5's behaviors were documented each hour by an RN, but not every 15 minutes by the PCT, which was the standard and which could have given timely insight into readiness for release. Hourly documentation revealed cumulative patient behaviors which were not real-time and could delay a timely release. In summary, inappropriate release criterion and scant behavioral documentation may have extended seclusion for pt. #5.

Based on a review of 7 open and 4 closed medical records, it was determined the hospital failed to document adequate discharge summaries for two records reviewed.

Per hospital policy titled, "Assessment/Reassessment of Patients" (03/2017) under section "C. Medical Staff" a discharge summary is to be completed. However, the policy does not specify a time frame of when. Patient # 9 was an adult patient who was admitted to the hospital's Critical Care Center in October 2018. Patient #9 had a length of stay of 5 days before expiring. There was no discharge summary found in the medical record.

Patient #10 had a document titled "Discharge Summary." Information about the patient's cardiac arrest and time of death was noted. However, no other components of the discharge summary were completed including the hospital course prior to the patient's demise.