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Based on interviews and document review, the Hospital failed to protect and promote the rights of patients and/or their patient representatives.


See tag 131.

Based on interviews and document review, the Hospital's Satellite Emergency Facility (SEF) failed to provide, for seven of fourteen patients (Patient #1, Patient #2, Patient #5, Patient #6, Patient #7, Patient #11, Patient #12) the patients' rights, including but not limited to: being informed of his/her health status, and being involved in the care planning and treatment. This includes patient representatives of the patients as six of the seven patients (Patient #1, Patient #2, Patient #5, Patient #7, Patient #11, and Patient #12) ranged in age from 1 month old to 7 years old.

Findings include:

Medical record review, conducted on 03/30/2022 at 1:10 P.M., of Patient #1 indicated that Patient #1 required the use of an interpreter (the "needs interpreter" designation was intended for the family of Patient #1 as Patient #1 was an infant). Review of the 07/01/2020 SEF visit (2nd to last SEF visit) did not indicate any evidence of interpreter services being used.

Medical record review of Patient #2 indicated that Physician #1 evaluated Patient #2 in the SEF on 09/17/2020. The record indicated that Patient #2 needed interpreter services in the language of Spanish. The record did not indicate that interpreter services for Patient #2 were ever utilized.

Additional record review conducted on 03/30/2022 at 1:10 P.M. identified other physicians at the SEF who evaluate and provide treatment to patients without the appropriate documentation and/or use of interpreter services. The medical records for the following additional patients indicated an interpreter was required, (as indicated under part of the patient demographics section that stated, Interpreter Needed: Yes.) yet there was no documentation in the patient's medical record that an interpreter was used during the visit. This was indicated for the following patients:

a) Patient #5: Interpreter Services needed. Preferred Language: Spanish. No indication in the medical record during a 03/13/2022 SEF visit was interpretive services used.

b) Patient #6: Interpreter Services needed. Preferred Language: Spanish. No indication in the medical record during a 03/06/2022 SEF visit was interpretive services used.

c) Patient #7: Interpreter Services needed. Preferred Language: Spanish. No indication in the medical record during a 03/12/2022 SEF visit was interpretive services used.

d) Patient #11: Interpreter Services needed. Preferred Language: Spanish. No indication in the medical record during a 03/29/2022 SEF visit was interpretive services used.

e) Patient #12: Interpreter Services needed. Preferred Language: Portuguese. No indication in the medical record during a 03/02/2022 SEF visit was interpretive services used.

The policy, titled "Provision of Interpreter and Translation Services" last revised 11/2021, states that all satellite providers and medical team members shall document the interpreter name or ID number and the modality of interpreter services that were utilized for all telephone and in-person encounters, including use of family members, or other companions. Any bilingual or multilingual provider or clinical staff that wishes to provide clinical care to Limited English Proficiency (LEP) patients in a language other than English, without the help of a medical interpreter, must pass a standard language fluency assessment provided by a vendor approved by the satellite organization. Passing a language fluency assessment will provide any bilingual or multilingual providers an Approved Bilingual Provider (ABP) status at the satellite organization. When working with LEP patients, ABPs shall document in the patient's chart that a medical interpreter was not utilized as ABP are fluent in patient's language.

The surveyor interviewed the Director of Regulatory/Accreditation on 03/30/2022 at 4:15 P.M. The Director confirmed that none of the attending providers who treated the above patients had a certification to speak in a language other than English, also known as an Approved Bilingual Provider or ABP status at the satellite location of the hospital.

Based on interviews and document review, the hospital satellite location failed to report a significant unexpected death, for one (Patient #1) of fourteen patients, to the Quality and Risk leadership department of the Main Hospital. The Main Hospital failed to measure, analyze, and track an adverse patient event that occurred at the satellite location. The Main Hospital failed to ensure, for 7 of 14 patients, that the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are consistently evaluated and monitored.


See tags 273 and 283.

Based on interviews and document review, a hospital satellite location of the Main Hospital failed to report a significant unexpected death, that occurred at their satellite emergency facility (SEF) for one (Patient #1) of fourteen patients, to the Main Hospital's Quality and Risk Management leadership.

Findings include:

It was reported, that on 07/01/2020 Patient #1 presented with a caregiver to the Satellite Emergency Facility (SEF) of the Main Hospital. The caregiver reported to hospital staff that Patient #1 was struggling to breathe and was purple for five minutes prior to arrival to the SEF. Patient #1 was evaluated and discharged home from the SEF approximately 22 minutes after arrival. Approximately 9 hours after the first SEF discharge, the caregiver presented again to the SEF with Patient #1. The caregiver reported to hospital staff that Patient #1 was crying, then stopped suddenly and became unresponsive. Patient #1 was unresponsive upon SEF arrival, and resuscitative efforts were initiated. Patient #1 was emergently transferred by Emergency Medical Services (EMS) to a tertiary facility. Patient #1 was pronounced dead shortly after arrival.

The surveyor interviewed the Risk Manager for the Main Hospital at 03/24/2022 at 11:11 A.M. The Risk Manager for the Main Hospital was never made aware of Patient #1's event by the satellite location's local leadership. Rather, Patient #1's event was only discovered by the Risk Manager of the Main Hospital when the Public Relations Department of the Main Hospital, in conjunction with the Chief Medical Officer of the Main Hospital brought Patient #1's event to the attention of the Risk Manager approximately 19 months post-event (event date July 2020), around February 2022. The Risk Manager said that the Public Relations Department of the Main Hospital identified Patient #1's unexpected death event via an article published by a local news agency, dated February 2022, describing Patient #1's alleged experience at the satellite location of the Main Hospital. The Risk Manager as well as the Quality and Risk Department of the Main Hospital was not aware of Patient #1's death event for the span of 19 months after the event occurred.

The surveyor interviewed the Executive Director of Quality and Risk (EDQR) for the Main Hospital, on 03/28/2022 at 10:15 A.M. The EDQR was not aware of Patient #1's death event at the time of the event in July 2020. The EDQR was made aware when the hospital satellite location's counsel notified the EDQR of the event around February of 2022, roughly 19 months after the event occurred.

Based on interviews and document review, the Main Hospital failed to implement a corrective action plan in an effective manner, for seven (Patient #1, Patient #2, Patient #5, Patient #6, Patient #7, Patient #11, Patient #12) of fourteen patients sampled. Although the hospital attempted to implement corrective actions, the hospital failed to track the performance of those corrective actions to ensure the desired improvements were sustained.

Findings include:

Medical record review, conducted on 03/30/2022 at 1:10 P.M., of Patient #1 indicated that Patient #1 required the use of an interpreter (the "needs interpreter" designation was intended for the family of Patient #1 as Patient #1 was an infant). Review of the 07/01/2020 SEF visit (2nd to last SEF visit) did not indicate any evidence of interpreter services being used.

The Root Cause Analysis (RCA), dated 08/05/2020, identified Physician #1's failure to utilize an interpreter for Patient #1, during Patient #1's 07/01/2020 SEF visit (second to last SEF visit), approximately 9 hours prior to Patient #1's death event, (last SEF visit).

An attestation statement signed by Physician #1 on a document titled "Language Assessment Testing," dated 07/23/2020, indicated that Physician #1 attested that: "I do not plan to use a language other than my native language in the care and treatment of patients without an interpreter." Physician #1 indicated English as a native language.

Medical record review of Patient #2 indicated that Physician #1 evaluated Patient #2 in the SEF on 09/17/2020. The record indicated that Patient #2 needed interpreter services in the language of Spanish. The record did not indicate that interpreter services for Patient #2 were ever utilized.

Additional record review conducted on 03/30/2022 at 1:10 P.M. identified other physicians at the SEF who evaluate and provide treatment to patients without the appropriate documentation and/or use of interpreter services. The medical records for the following additional patients indicated an interpreter was required, (as indicated under part of the patient demographics section that stated, Interpreter Needed: Yes.) yet there was no documentation in the patient's medical record that an interpreter was used during the visit. This was indicated for the following patients:

a) Patient #5: Interpreter Services needed. Preferred Language: Spanish. No indication in the medical record during a 03/13/2022 SEF visit was interpretive services used.

b) Patient #6: Interpreter Services needed. Preferred Language: Spanish. No indication in the medical record during a 03/06/2022 SEF visit was interpretive services used.

c) Patient #7: Interpreter Services needed. Preferred Language: Spanish. No indication in the medical record during a 03/12/2022 SEF visit was interpretive services used.

d) Patient #11: Interpreter Services needed. Preferred Language: Spanish. No indication in the medical record during a 03/29/2022 SEF visit was interpretive services used.

e) Patient #12: Interpreter Services needed. Preferred Language: Portuguese. No indication in the medical record during a 03/02/2022 SEF visit was interpretive services used.

The policy, titled "Provision of Interpreter and Translation Services" last revised 11/2021, states that all satellite providers and medical team members shall document the interpreter name or ID number and the modality of interpreter services that were utilized for all telephone and in-person encounters, including use of family members, or other companions. Any bilingual or multilingual provider or clinical staff that wishes to provide clinical care to Limited English Proficiency (LEP) patients in a language other than English, without the help of a medical interpreter, must pass a standard language fluency assessment provided by a vendor approved by the satellite organization. Passing a language fluency assessment will provide any bilingual or multilingual providers an Approved Bilingual Provider (ABP) status at the satellite organization. When working with LEP patients, ABPs shall document in the patient's chart that a medical interpreter was not utilized as ABP are fluent in patient's language.

The surveyor interviewed the Director of Regulatory/Accreditation on 03/30/2022 at 4:15 P.M. The Director confirmed that none of the attending providers who treated the above patients had a certification to speak in a language other than English, also known as an Approved Bilingual Provider or ABP status at the satellite location of the hospital.