HospitalInspections.org

Based on record review and interview the facility failed to provide a Limited English Proficient (LEP) patient with oral and/or written information on patient rights in a language of which they can competently understand for 1 [P(patient)8] of 20 (P1-P20) patients reviewed. This failed practice likely led to the violation the patient's right to informed consent, and the right to be free from abuse, neglect, and harassment.
The findings are ...

A. Record review of Facility's Policy titled, "Language Interpreter Services," dated 04/13/2021, revealed page 3.4.1 "Hospital-provided interpreters are part of the care team, and as such should be present during medical interpretation with LEP (Limited English Proficient) patients, when direct care in the patient's language cannot be given by the provider."

B. During an interview on 09/14/2022 at 4:20 pm with S18, Outpatient Clerk, when asked about the process for obtaining consent for treatment when the patient does not speak English, S18 states, "We have interpreters and if not, we have interpreter phones."

C. Record review of P8, History & Physical (H&P) Assessment, dated 07/02/2022 at 3:59 am, revealed "[patient (pt) age] Korean speaking [pt gender] s/p (status post) MVC (motor vehicle crash) at highway speed ... GCS (Glascow Coma Scale) 14 ( a tool used to measure level of consciousness; the scale ranges 3-15, 3 being completely unresponsive or dead and 15 being walking, talking, and oriented to self, time, place, and situation). Unable to obtain history due to unavailability of Korean interpreter ... Mental Status: alert, unable to assess orientation," signed by Medical Doctor (MD).

D. Record review of P8, Consent Form, dated 07/02/2022 revealed English and Spanish text only, and a signature of "unable," one witness signature and no signature for legal representative.

E. Record review of Facility's Policy titled, "Language Interpretive Services," dated 04/13/2021, revealed page 3.4.2, "The hospital will not use family members or other non-qualified interpreters except in unusual circumstances. If the LEP patient requests their own interpreter in lieu of a hospital-provided interpreting service, the refusal and request will be documented in the patients record, along with the name, DOB (date of birth) and relationship of the individual to the patient."

F. Record review of P8, Medical Record, dated 07/02/2022-08/02/2022, documented an interpreter was either present, contacted, or attempted contact on the following dates and times:
a. 07/04/2022 -8:00 am, 7:30 pm, 8:00 pm
b. 07/05/2022 -4:00 am
c. 07/08/2022 -8:00 pm
d. 07/09/2022 -"Interpreter not available. Tried calling"
e. 07/10/2022 -8:00 am "unable to get a hold of interp(interpreter)," 8:00 pm
f. 07/12/2022 -8:00 am
g. 07/13/2022 - 8:01 am, 8:00 pm
h. 07/14/2022 - 8:00 am, 6:00 pm, 8:00 pm
i. 07/15/2022 - 8:00 am, 6:00 pm
j. 07/17/2022 - 8:00 am
k. 07/18/2022 - 8:00 pm
l. 07/19/2022 - 8:00 am
m. 07/20/2022 - 8:00 am "pt. (patient) unable to speak coherently (understandably)."
n. 07/21 - 07/26/2022 - "No interpreter services used / family noted present to translate."
o. 07/27/2022 - 8:00 am
p. 07/28/2022 - 07/30/22 - "no interpreter needed, pt. understands as well as son."
q. 07/31/2022 - 8:00 am, 6:00 pm
r. 08/01/2022 - 8:00 am - "pt. declined interpreter services."

G. Record review of P8, Medical Record, dated 07/02/2022-08/02/2022, revealed no use or attempted use of an interpreter for the following dates:
a. 07/02, 07/03, 07/06, 07/07, 07/11, 07/16, 07/29, 07/30, and 08/02/2022.

H. Record review of P8, Physician Orders, dated 07/02/2022-08/02/2022 revealed orders were placed for Physical restraints (any manual method, physical or mechanical device, equipment or material, that is attached or adjacent to the patient's body, cannot be removed easily by the patient, and restricts the patient's freedom of movement or normal access to his/her body) on the following dates:
a. 07/03/2022 -5:17 pm; order entered by MD 07/07/2022 at 1:46 pm, "I have had a face to face evaluation of the patient and agree that a restraint is needed to protect, Soft."
b. 07/04/2022 -6:07 am; order entered by MD 07/07/2022 at 1:46 pm, "I have had a face to face evaluation of the patient and agree that a restraint is needed to protect, Soft."
c. 07/05/2022 -6:40 am; order entered by MD 07/07/2022 at 1:46 pm, "I have had a face to face evaluation of the patient and agree that a restraint is needed to protect, Soft."
d. 07/06/2022 -11:30 am; order entered by MD 07/07/2022 at 1:46 pm, "I have had a face to face evaluation of the patient and agree that a restraint is needed to protect, Soft."
e. 07/07/2022 -1:43 pm; order entered by MD 07/08/2022 at 5:32 am, "I have had a face to face evaluation of the patient and agree that a restraint is needed to protect, Quick release | Soft, No longer interfering w/ Nec Med (necessary medical) Care, Interfering with medical devices | devices | Interfering with tubes/drains."
f. 07/08/2022 -5:32 am; order entered by MD 07/08/2022 at 5:32 am, "I have had a face to face evaluation of the patient and agree that a restraint is needed to protect, Quick release | Soft, No longer interfering w/ Nec Med Care, Interfering with medical devices | devices | Interfering with tubes/drains."
g. 07/09/2022 -8:12 am; order entered by MD 07/09/2022 at 8:12 am, "I have had a face to face evaluation of the patient and agree that a restraint is needed to protect, Quick release | Soft, No longer interfering w/ Nec Med Care, Interfering with medical devices | devices | Interfering with tubes/drains."
h. 07/14/2022 -9:52 am; order entered by MD 07/17/2022 at 3:03 pm, I have had a face to face evaluation of the patient and agree that a restraint is needed to protect, Soft, No longer interfering w/ Nec Med Care, Interfering with medical care."

I. Record review of P8, Medical Record, dated 07/03/2022, revealed patient was placed in physical restraints without appropriate communication and de-escalation techniques (strategically employed verbal and nonverbal interventions used to reduce the intensity of threatening behavior before, during, and after a crisis situation occurs) as interpretive services were not utilized that day.

J. Record review of P8, Medical Record, dated 07/06/2022, revealed patient was placed in physical restraints without appropriate communication and de-escalation techniques as interpretive services were not utilized that day.

K. Record review of P8, Medical Record, dated 07/07/2022, revealed patient was placed in physical restraints without appropriate communication and de-escalation techniques as interpretive services were not utilized that day.

L. Record review of P8, Medical Record, dated 07/07/2022, revealed patient was intubated (placed on a mechanical ventilator as a form of life-support), without appropriate communication or opportunity for informed consent.

M. Record review of P8, PowerChart: Nursing, dated 07/05/2022 at 7:00 am, documented, "PT agitated at change of shift, trying to take off miamiJ (a form of cervical spine (neck) stabilization device), in restraints and mittens. Provider in room, medications to be discussed during rounding. PT's first language is Korean."

N. Record review of P8, PowerChart: Nursing, dated 07/05/2022 at 8:13 pm, documented, "Pt agitated. Pulling off EKG (electrocardiogram) leads (a set of patches specifically developed and applied to the surface of the skin in order to read the electrical conduction of the heart), Almost pulled out an IV (intravenous catheter, an invasive line used to deliver medications directly into the bloodstream). Telemonitor (an electronic device used to monitor the patient remotely. In this application, the patient is monitored by video in place of a sitter, a person who is continuously at the patient's bedside to redirect the patient in the event of adverse behavior) already in the room but pt doesn't speak english [sic] so is not redirectable."

O. Record review of P8, PowerChart: Nursing, dated 07/05/2022 at 8:50 pm, documented, "Trauma Rojo (a team of medical providers assigned to the care of individual patients throughout the facility) notified patient now in 4 point soft wrist restraints [sic] (a form of mechanical restraint in which all four extremities, both arms and legs are immobilized as they are secured to the frame of a hospital bed, in this case using restraints that are made of a soft foam or polyester material rather than a harder material) for patient safety." Record review revealed no attempted use of interpreter services in an effort to de-escalate or redirect patient on 07/05/2022 at or leading up to 8:50 pm.

P. Record review of P8, PowerChart: Nursing, dated 07/10/2022 at 6:23 am, documented, "0621(6:21 am) - Dangerously combative, attempted to kick bedside nurse in the head. Not verbally re-directable." Record review revealed no attempted use of interpretive services in an effort to de-escalate or redirect patient on 07/10/2022 at or leading up to 6:21 am.

Q. Record review of P8, PowerChart: Nursing, dated 07/11/2022 at 9:00 am, documented, "Patient kick and trying to fight nurse during exam." Record review revealed no attempted use of interpretive services in an effort to de-escalate or redirect patient on 07/11/2022.

Based on record review and interview the facility failed to ensure patients have the right to make informed decisions regarding his/her care through properly documented Consent to Treatment for 6 patient (P) (P 1, P11, P12, P13, P18, P20) of 20 (P1-P20) patients reviewed. This failed practice can lead to patients not giving their consent for treatment being provided and can lead to patient harm.

The findings are as follows:

A. Record review of facility policy titled, "Admitting Patient Consents" effective date 01/12/22 stated under Procedure #2, "A consent form is to be signed for each admission." Under Procedure #3, "the admitting representative is to read/explain each section of the consent form and have the patient and/or their guarantor or representative sign at the bottom of the consent form acknowledging that the entire consent form was explained, and the contents were understood." Under Procedure: #5, "If the patient and/or their guarantor or representative cannot physically sign, but instead give verbal consent, the admitting representative will need a second staff member to sign as a witness."

B. Record review for P1, date of admission 05/29/22 facility "Consent form" under "Patient's signature" revealed "unable" written in with no reason why the patient was unable to sign. The document has one witness initials, no date noted.

C. Record review for P11, date of admission 06/11/22, facility "Consent form" under "Patient's signature" revealed "unable-AMA (against medical advice)" written in with no reason why the patient was unable to sign. The document has one witness signature and date noted.

D. Record review for P12, date of admission 05/18/22, facility "Consent form" under "Patient's signature" revealed "unable (custody)" written in with no reason why the patient was unable to sign. The document has one witness initials with date noted.

E. Record review for P13, date of admission 07/15/22, facility "Consent form" under "Patient's signature" revealed "unable-ems (emergency medical services)" written in with no reason why the patient was unable to sign. The document has one witness initials with date noted.

F. Record review for P18, date of admission 07/24/22, facility "Consent form" under "Patient's signature" revealed "Pt (patient) left AMA (Against Medical Advice)" written in and is dated 07/26/22 with no reason why the patient was unable to sign at admission or throughout the stay. The document has one witness signature, no date noted.

G. Record review for P20, date of admission 06/25/22, facility "Consent form" under "Patient's signature" revealed "unable" written in with no reason why the patient was unable to sign. The document has one witness signature with date noted.

H. On 09/14/22 at 4:20 pm during interview with S (staff)18 (Outpatient Clerk) and S19 (Outpatient Clerk Supervisor) who confirmed, "If the patient is verbal and consensual, they initial and sign, if they are not consensual (can't sign, have a guardian or are a child, altered, trauma or any reason they cannot sign) we will note it on the consent form. There are times when we are rushed, and we just write "unable." [Question to staff: How many attempts are made to obtain consent?] We will only put verbal if a patient is unable to use their hands, we will list them as verbal and will note it on the consent form. The consent form is the last of their[patient] worries so it can be difficult. Patients with traumas can't always get consent. If a patient cannot physically sign is when we write verbal. On an average day there are 200 and up patients in the ER (Emergency Room) and 80% we get consents signed. We have started the process of having the patients sign right away so that the document can get scanned into the patient's file sooner.

Based on record review and interview the facility failed to complete a discharge plan for 3 [P (patient)12, P13, and P18] of 20 (P1-P20) vulnerable patients (those who are incapable of protecting their own interests and are therefore susceptible to physical, psychological, and emotional harm and/or neglect) reviewed. This failed practice could lead to unnecessary readmittance within a 30-day period for the same or related diagnoses, patient harm, and a violation of the patients' right to be included in care planning, and to make informed decisions.

The findings are ...
A. Record review of Facility's Policy titled, "Discharge Planning," dated 05/21/2021, revealed page 1. para (paragraph) 4 "The initial discharge planning will also include a readmission risk assessment to identify inpatients at risk for adverse health conditions during transitions of care ... The RN CM (Registered Nurse Case Manager) will consult with the SW CM (Social Work Case Manager) when social work triggers are identified during initial assessment (see attachment A) ...
a. Attachment A: Social Work Triggers ...
i. Frequent readmission or frequent ED (Emergency Department) utilization...
ii. Vulnerable adults...
iii. Suicidal/homicidal ideation (thoughts of harming self or others) ...
iv. Inability to meet basic personnel [sic] needs due to incapacity (being incapable) or behavioral issues (issues with behavior) ...
v. Developmental delay/issues with unmet needs...
vi. Mental Health issues/concerns."

B. Record review of Facility's Policy titled, "Discharge Planning, dated 05/21/2021, revealed page 2. para 7 "Discharge planning assures continuing and comprehensive care for the patient at the appropriate level of care. Discharge planning is provided for all patients who require our services."

C. During an interview on 09/13/2022 at 3:05 pm with S21, Director of Care Management Services, when asked if all patients see a discharge planner, S21 stated, "all patients do not see one unless the patient has specific needs that need to be addressed."

D. Record review of Facility's Policy titled, "Suicide Screening and Precautions" dated 12/03/2021, revealed page 4 "Discharge and Follow-up Plan ... 2. For inpatient adults and children who screen as moderate to high risk, the consulting psychiatric service will provide discharge documents including a safety plan, follow-up plan based on risk level, and crisis call center numbers."

Patient 12:
E. Record review of P12, Patient Admissions, all dates, revealed patient discharge and readmission within the same 30-day period for the following dates:
a. Admission to ED (Emergency Department) for short stay 05/14/2022 at 5:35 pm, discharge 05/15/2022 at 11:25 am.
b. Admission to Medicine Zinc3 (a team of medical providers assigned to the care of individual patients throughout the facility) for inpatient on 05/18/2022 at 2:20 pm, discharge 05/18/2022 at 2:51 pm.
c. Admission to Medicine Zinc3 for short stay on 05/19/2022 at 4:00 am, discharge 05/20/2022 at 12:09 pm.

F. Record review of P12, Care Management (the management of a patients care), revealed no RN CM or SW CM discharge note planning for admission/discharge dated 05/18/2022.

G. Record review of P12, First Net Nursing Screening (initial nursing assessment/screening), dated 05/18/2022 at 12:32 pm, documented, "Pt (patient) was seen here 3 days ago for same complaint."

Patient 13:
H. Record review of P13, Patient Admissions, all dates, revealed patient discharge and readmission within the same 30-day period for the following dates:
a. Admission to P-ED (Pavilion Emergency Department) for emergency on 07/15/2022 at 10:26 pm, discharge 07/16/2022 at 6:35 pm.
b. Admission P-ED Trauma for emergency on 07/17/2022 at 1:54 am, discharge 07/18/2022 at 10:16 am.

I. Record review of P13, Care Management, dated 07/18/2022 revealed no RN CM or SW CM discharge note or planning.

J. On 09/14/2022 at 9:34 am, during an interview with S20, Nursing Informaticist on 09/14/2022 at 9:34 am, when asked to review the Care Management note for P13's 07/18/2022 admission, S20 stated, "I don't have a discharge, not for that visit."

Patient 18:
K. Record review of P18, Patient Admissions, revealed P18 was admitted on 07/24/2022 at 8:56 am, and discharged 07/26/2022 at 7:39 pm.

L. Record review of P18, Care Management, dated 07/24-07/26/2022 revealed no discharge note or planning by RN CM or SW CM.

M. On 08/14/2022 at 10:44 am, during an interview with S20, when asked to review the Care Management (discharge planning) note for P18, S20 stated, "I don't see that there is one."