HospitalInspections.org

Based on record review and interview, the hospital failed to follow the facility's policy and procedures to ensure patients receive appropriate language translation services to exercise their right to make informed decisions in their care in 2 of 3 patients receiving language translation services (Patient #1 and #8).

Findings include:

Review of facility's policy titled "Provision of Language Services" #1491117, last revised 11/2015, expiration 11/2018, defined interpreting as "communication between individuals that do not speak the same language facilitated by a third party is fluent in both languages and acts as a conduit of oral communication". The policy revealed "for the safety and protection of our staff and patient, associates who have not successfully completed CSM's [Columbia St. Mary's] competence assessment are not to be used to perform third party interpreting for patients or providers. At present we offer this testing for Spanish and Russian". Under A. Direct Level/Basic Communicator "a bilingual person ... is not automatically so qualified by virtue of his/her language abilities". Under Process #1 "At all points of initial contact upon entering our healthcare system, an assessment and determination of each patient's communication needs is to be made. A staff member is to inform patients ... that confidential language services are available at no cost to the patient to assist them in communicating with our staff and medical providers ... This identification should be reviewed and updated regularly to indicate any change in their need for language assistance". An external Over the Phone Interpreting Service "is accessible 24 hours a day, 7 days a week ... should primarily be used to communicate with a patient or family members when the need for the interpreter is 15 minutes or less". If patient choses to use family members, friends, or other designated interpreters, they must be informed that interpreter services are free and informed of the risks and liabilities in the use of designated interpreters acting as a medical interpreter. "The CSM [Columbia Saint Mary] representative shall ensure that a "Patient Waiver for Use of CSM Interpreter" form be signed by both the patient and the designated interpreter to document that both parties understand the consequences of using an untrained interpreter in a medical encounter. C. This signed and dated information will be included in the patient's electronic health record (EHR)".

Review of Patient #1's medical record revealed the following: admission consent form, written in English, titled "Conditions of Treatment" under Patient Rights and Responsibilities "I acknowledge that I have received a copy of Columbia St. Mary's Patient's Right and Responsibilities Brochure" revealed Patient #1's signature under "THE UNDERSIGNED HAS READ AND UNDERSTANDS THE ABOVE" dated 11/26/17 at 1 PM. There was no documentation to verify the consent information was interpreted for Patient #1.

History and Physical dated 11/26/17 at 5:08 PM, titled "Hospitalist H&P *Final Report*" by Physician O, for Patient #1 revealed "83yo Russian speaking F [female]...who presents prior to elective nephrectomy. Attempted to use the blue phone (special phone service which provides interpreter access over the telephone used in urgent situations or when agency interpreter cannot be obtained) however pt [patient] could not cooperate with the phone interpreter so family member was used for history". The English written consent for the left nephrectomy conducted on 11/26/17 failed to include the interpreter who translated the consent information for Patient #1. "Patient Waiver for use of CSM [Columbia St. Mary] Interpreter" printed in Russian, was dated 11/27/17, but the waiver signed by Patient #1 was not timed to verify this consent was signed prior to initiation of anethesia.

Progress note by Registered Nurse R dated 12/09/17 at 8:38 PM, revealed "Bronchoscopy was done by [Physician Q] at [3:30 PM]...language Translation for doctors were done by writer". No consent for this procedure was found in Patient #1's medical record. Operative/Procedure note dated 12/15/17 at 6:08 PM, titled "Stamam Gastrostomy/Jejunostomy and Tracheostomy" by Doctor S indicated procedures were performed, no procedure consents for Stamam Gastrostomy/Jejunostomy or tracheostomy procedures were found in Patient #1's medical record.

Review of Patient #8's medical record emergency room progress note by Doctor T titled 'Final Report" dated 11/16/17 at 11:15 PM under history of present illness revealed Patient #8 "is Spanish- speaking with [family P] acting as translator". "Authorization and Consent to Operation/Procedure/Treatment" form, written in Spanish, had no physician name written in. Under section #1 "blood transfusion" was written in English, and section #2 were circled. Interpreter line was blank. There was no physician signature, date, or time.

Gastroenterology Consult dated 11/17/17 at 9:46 AM titled "Final Report" under Basic Information revealed family P "acts as /Spanish interpreter for pt [patient] who is reliable".There was no documentation indicating any interpreting services were offered. There was no "Patient Waiver for Use of CSM Interpreter" form in patient #8's medical record.

An interview was conducted with Quality Outcomes staff C. C confirmed there were no procedure consents for the bronchoscopy or Stamam Gastrostomy/Jejunostomy and Tracheostomy procedures in Patient #1's medical record.

An interview was conducted on 1/18/2018 at 1:55 PM with Clinical Nurse Specialist D. D confirmed that a "Patient Waiver for Use of CSM Interpreter" form was not in Patient #8's medical record and nothing was documented indicating that Patient #8 was offered translation services for communication with the medical providers.

An interview was conducted on 1/18/18 at 3:10 PM with Regional Manager of Lanuage K. During review of the list of Bilingual Associates who have passed the bilingual associate assessment, under column titled "Spanish/Russian" revealed Spanish associates only. K confirmed there were no Russian associates who have passed the bilingual associate assessment.

Based on record review and interview, the facility failed to follow their policies and procedures to ensure consents were appropriately obtained in 5 of 9 patients requiring informed consent prior to their procedure (Patient #1, #2, #3, #6 and #8).

Findings include:

Review of facility policy titled "Patient Care-Consent for Treatment-Procedures" #4430190, last revised 07/2017 expiration 07/2020 under Process, 4. Informed Consent: A. "Informed consent must be obtained for the following procedures ... 3. Transfusion of blood or blood products ... B.Telephone consent... must include the elements of informed consent noted in this policy... should be noted in the patient's medical record and witnessed within 24 hours". Under C 1. "The physician* who is responsible for the operation, procedure or treatment must sign, date and time the section of the form entitled, Risks, Benefits and Alternative Modes of Treatment prior to the start of the operation, procedure or treatment. (Note: This includes administration of blood/blood products".

Review of facility's policy titled #Blood - Blood Product Administration" #4154350 Last Revised 10/2017, expiration 10/2020 under procedure #4 "verify presence of physician documentation of informed consent ... 17. Verifications to be done prior to administration ... B. Consent documented".

Review of Patient # 1 medical record revealed form titled "Authorization and Consent to Operation/Procedure/Treatment" section #2 for Blood and Blood Product Administration circled, revealed no Physician name written in. The signature line date and time for the patient and medical doctor were left blank.

Progress note by Doctor Q titled "Pulmonary Attending Addendum" dated 12/09/17 revealed "bronchoscopy performed".
Operative/Procedure note dated 12/15/17 at 5:49 PM titled "Stamam Gastrostomy/Jejunostomy and Tracheostomy" by Doctor S revealed procedure was performed. No procedure consents for bronchoscopy, Stamam Gastrostomy/Jejunostomy or tracheostomy procedures were found in Patient #1's medical record.

Review of Patient #2's medical record revealed form titled "Authorization and Consent to Operation/Procedure/Treatment" section #2 for Blood and Blood Product Administration circled, revealed no physician name written in. The medical doctor signature line, date, and time lines were left blank.

Review of Patient #3's medical record form titled "Authorization and Consent to Operation/Procedure/Treatment" revealed bone marrow aspiration core biopsy written in section #1, the witness signature date, and time were blank.

Review of Patient # 6's medical record form titled "Authorization and Consent to Operation/Procedure/Treatment" for Bronchoscopy with Laryngoscopy written in revealed the witness signature date, and time were blank.

Review of Patient #8's medical record revealed form in Spanish language titled "Authorization and Consent to Operation/Procedure/Treatment" with no physician name written in. The blood transfusion consent written in English under section #1 and #2 were circled. The interpreter line was blank and the physician signature, date and time were blank.

An interview was conducted on 1/18/18 during chart reviews between 1:15PM and 2:50 PM with Clinical Nurse Specialist D. D stated that informed consents are to be filled out completely with the physicians name who had explained the procedure, the procedure written out, signed, dated, and timed by the physician with a witness signature, date, and time witnessed documented.

An interview was conducted on 1/18/18 at 2:10 PM with Quality Outcomes staff C. C verified that there were no consents for the bronchoscopy, Stamm Gastrostomy, Jejunostomy and Tracheostomy procedures conducted on Patient #1 on 12/09/17 and 12/15/17.