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Based on review of the medical records, staff interviews, policies and procedures, and observations, it was determined that the hospital failed to obtain informed consent or explain to patient #32 information regarding her care and the use of restraint, when they failed to provide her with translator services, after having identified that the patient spoke and understood limited English and that her primary language was Spanish.


Per policy the patient's rights and responsibilities should be provided and explained in a language or manner that the patient (or the patient's representative) can understand. The Interpretive Services and Other Communication Services state under policy:

"In order to insure that patients receive necessary care, the hospital will provide the means of effective communication with patients and family members who do not speak English or who specify a preferred language other than English for the health care encounter and/or individuals who are deaf or hearing impaired." In bold blackened letters "Family members may not act as an interpreter for the patient."

The hospital provides access to interpreter services such as the Cyracom Language Line (interpreters for phone calls), on-site certified Russian Interpreter Service, Qualified Bilingual Interpreters, and sign language interpreters. The policy for Interpreter Services under procedure states "referral guidelines for the health care team will be made to the appropriate Interpreter Service Resource to facilitate communication between patient and/or family with health care team to ensure the patient/family possesses an understanding of the following patient care concerns: a) Informed consent-explanation of proposed treatment or procedures including risk factors, as well as alternatives to proposed care plan, advance directives, identity of primary physicians, Discharge/Education Instructions, resolution of conflicts, withholding resuscitation and withholding/withdrawing life-sustaining treatments, and any other health care concerns."


Patient #32 was admitted to the hospital on 1/26/14 at approximately 10:15 AM from another facility for assaultive behavior toward her roommate and staff. On the Comprehensive Behavioral Assessment, a psychiatric evaluation tool, from the sending hospital stated "(speaks Spanish)." The patient was placed in restraints at 10:33 AM with no documentation that a interpreter was used to assess the patient thought process, initiate least restrictive interventions including the administration of IM (inramuscular) medication, and the initiation of restraints.

The medical record revealed that on 1/26//14 at 1:00 PM in the behavioral assessment the patient speaks little to no English and that her son was present and cooperated by interpreting. Throughout the documentation, it was documented that the patient spoke little to no English and that the son was used as an interpreter. The patient remained in restraint until 6:30 PM on 1/26/14. Without the use of an interpreter, it is not known if the patient understood what was happening to her or that the staff assessed the patient's thought process.

The failure to use the interpretive service or language line failed to give the patient the opportunity to understand what was expected of her and her care options since she may not have understood what was said to her. In addition, what the patient said to the staff was interpreted by the son, which may not have been interpreted just as the patient had stated. There was one note written on 1/27/14 at 8:50 AM that the nursing staff used the language line for interpretation. The hospital failed to assist the patient to participate in her care by failing to provide interpretive services. There is question as to whether the patient understood what was happening to her during the restraint process, understood the reason for restraint, or criteria for release.

based on review of the medical records for 1 of 30 patients reviewed , it was determined that patient #32 was placed in restraints without benefit of an interpreter for her assessments.

Patient #32 was placed in restraints at 10:33 AM with no documentation that a interpreter was used to assess the patient thought process, initiate least restrictive interventions including the administration of IM medication, and the initiation of restraints. The every fifteen minutes monitoring revealed the patient as alert and oriented, calm and cooperative after the initial reason for restraint.

The medical record revealed that on 1/26//14 at 1:00 PM in the behavioral assessment the patient speaks little to no English and that her son was present and cooperated by interpreting. Throughout the documentation it was documented that the patient spoke little to no English and that the son was used as an interpreter. The patient remained in restraint until 6:30 PM on 1/26/14. Without the use of an interpreter, it's not known if the patient understood what was happening to her or that the staff assessed the patient's thought process. The failure to use the interpretive service or language line failed to give the patient the opportunity to understand what was expected of her and her care options since she may not have understood what was said to her. In addition, what the patient said to the staff was interpreted by the son, which may not have been interpreted just as the patient had stated. There is question if the patient understood what was happening to her during the restraint process, understood the reason for restraint, and criteria for release. The hospital failed to document criteria for release or based on the monitoring release the patient as the earliest possible time from restraints.

Based on review of the medical records for two of thirty patients reviewed it was determined that properly executed informed consent forms were not available for transfer to another facility.

Patient #14 is a 27 year old female who arrived at Sinai Hospital's Emergency Department with complaints of severe headache, blurred and double vision. Patient #14 also had a past history of Pseudotumor cerebri; a condition in which the pressure inside the skull (intracranial pressure) increases.

A medical screening and diagnostic studies were completed and the physician determined that Patient#14's cerebral shunt would require revision. Transport arrangements were made to transfer Patient #14 to a higher level of care at another hospital for the cerebral shunt revision. However, further review of the Patient Transfer Form indicates that the form was not completed prior to the patient's transfer. Specifically, the form lacks Patient #14's signature consenting to the transfer and attestation that the patient understood the risk and benefits of the transfer. The form also lacks signature of a witness and current date in both sections.

Patient # 15 is a 90 year old female who arrived at Sinai Hospital 's Emergency Department with complaints of severe pain after having sustained a fall. A Medical screening with diagnostic studies was completed. Per documentation in the ED transfer form, Patient #15's insurance carrier subsequently requested that Patient #15 be transferred to an affiliated local hospital for continued care.

On further review of the medical record, specifically the patient transfer form, the ED physician contacted physicians at the affiliated hospital who accepted Patient #15 for transfer. However, the transfer form lacks Patient #14's signature consenting to the transfer and attestation that she understood the risk and benefits of the transfer. The form also lacks the signature of a witness, current date, and initials of the RN under the nursing checklist indicating that pertinent copies of the medical record, lab reports, patient valuables, and a nursing report had been sent to the receiving facility. In addition, the form lacks documentation of Patient #15's departure vital signs and the RN's signature at the time of departure. .

Based on review of the hospital policy and the review of 30 medical records, it was determined that two patients were not reassessed in excess of two hours subsequent triage but before receiving a medical screening examination.

Per the hospital policy and procedure for Triage Five (5) Tier Emergency Severity Index System (ESI) Guidelines, all patients seeking or requesting treatment in the Emergency Department will be triaged and receive a MSE (Medical Screening Examination) in compliance with the Federal EMTALA legislation. Under procedure it states patients will be classified based on the ESI level system at time of arrival/triage by a RN. Patients will be prioritized according to the acuity classification. The patient is assessed for priority according to, but not limited to: chief complaint with associated symptoms, vital signs to include pain level, body temperature for children under age 3, and general appearance including airway, breathing, circulation, and neurology status. Per the policy an ESI 3 level is a patient who is considered stable but potential to become unstable and the patient requiring 2 or more resources with vital signs not in danger zone. Number 10 under procedure states " patients should have repeat vital signs every 2 hours or more frequently based on clinical condition while waiting to be taken back to the treatment area. Repeat vital signs will include ABC assessment to include respiratory rate, pulse oximetry and heart rate. The blood pressure and temperature will be reassessed based on clinical judgment of the nurse."

Patient #18 visited the ED on 1/5/14 with multiple complaints including headache, stomach pain, body-aches, nausea and neck pain. The patient was triaged at 7:17 PM with notes regarding vital signs around the same time. The patient was an ESI 3 with pain level 7. The next note timed 11:48 PM noted when they looked for the patient to perform the medical screening examination the patient had left the ED. This patient had been in the emergency department for 4 hour without an indication of reassessment including vital signs or pain assessment.

Patient #19 visited the ED on 1/5/14 with infected hole in his leg. The patient was triaged at 7:31 PM and although admitted the patient's medical screening examination was performed on 1/6/14 at 4:46 AM. The patient was ESI 3 with pain level of 8. For a patient at this ESI level and pain score of 8, he should have been assessed and seen by the physician in a timely manner rather than 8 hours from the triage time.

In the case of both patients they were triaged with ESI 3 levels and pain score greater than 5 on pain scale of 1-10. Patient #18 had no evidence in the medical record of reassessment of vital signs or pain assessment and when staff went to call her back for MSE, the patient had left the ED with a total time of 4 hour in the ED. Patient #19 also had no evidence of reassessment for vital signs and pain and it was 8 hours before his medical screening examination was performed. The ED census for 1/5/14 1500 to 1/6/14 0800 revealed a census of 100 with gradual drop to 80s and low 70s. Per the Maryland CHAT Alert system for Region III, the hospital was on yellow alert from 1/5/14 1635 to 1/5/14 1818. The yellow alert means the hospital's ED temporarily request that it receive no patients in need of urgent medical care via 911. The hospital was not placed on any other type of alert until 1/6/14 at 1100. The ED was very busy but both patients had the potential to become unstable and were not being reassessed for pain and stability while waiting for the medical screening examination.