HospitalInspections.org

Based on interviews with staff, review of policies, procedures, and other documentation inclusive of 14 medical records during an unannounced complaint (MD00138905 and MD00141147) survey on June 17-18, 2019, it was determined that the facility was out of compliance with the Condition of Participation for Patient Rights related to:

1. Failing to provide consistent interpreter services to a patient with limited English proficiency and as a result failing to allow this patient to meaningfully participate in care planning and treatment (A-131).
2. Allowing general consent forms to be signed by surrogates for patients where no incapacity had been determined (A-131).
3. Failing to comply with patient's advanced directive wishes to receive life-saving interventions due to absence of ordered clinical monitoring (A-131).
4. Failing to obtain physician orders for violent restraints for two patients (A-168).
5. Failing to provide a face-to-face assessment to two patients in violent restraints (A-178).

Based on a review of three patient records, the hospital policy for "Patient Rights" (revision 10/15), the "Patient and Visitor Information Guide", the "Adult Behavioral Health Patient and Family Handbook", and "Services for Limited English Proficient Deaf & Hearing Impaired (last hospital review 10/18)", it was determined that the facility failed to allow patient #6 (P6), patient #5 (P5) and patient #13 (P13) to exercise their rights to make informed decisions about their health by 1) not informing Behavioral Health Unit (BHU) patients of the right to an interpreter; 2) failing to obtain consistent interpreter services for P6; and 3) allowing general consent forms to be signed by surrogates for P5 and P13 where no incapacity had been determined.

The findings include:

Review of the "Adult Behavioral Health Patient and Family Handbook," which was given on admission to BHU patients revealed no information regarding the right to an interpreter. Therefore, BHU patients were not informed of their right to interpreter services.

Review of "Services for Limited English Proficient Deaf & Hearing Impaired" revealed in part, "It is important that the patient's medical record reflects the name of the interpreter, as well as the date and time of day that he/she worked with the patient to include the total time spent with the patient. This information should be recorded in the general nursing comment note." Review of the record for P6 found no instances of documentation as required by policy.

Patient #6 (P6) was a young non-English speaking adult patient who presented to the emergency department following self-harming behaviors and was subsequently admitted to BHU. Review of P6's record revealed that inconsistent interpreter services were obtained for treatment planning, group therapy, and education. Disparities of interpreter services for P6 were noted as:

1. When P6 arrived in the ED, P6 was identified as non-English speaking. No documentation was found that an interpreter was provided for P6 in ED or when P6 was admitted to the BHU for being a danger to self. A nursing notation on the initiation of "Inpatient Master Treatment Plan" for the BHU stated in part, "Pt is Spanish Speaking, Very little English. Assessment done at night pt tired limited info."

2. A "Condition of Treatment" consent which was printed in English was signed by P6 and no evidence of an interpreter was found.

3. Documentation gathered on the BHU during on-site survey revealed P6's signature on the "Master Treatment Plan" for day 3 of admission under a printed statement, "I have participated in the development of this plan or treatment and agreed to its implementation." Signatures with dates and time also included the psychiatrist, social worker, nurse, and recreational therapist. The form had a place for "Other signature" which was blank. It was apparent that the hospital failed to provide an interpreter at the time of patient review of treatment plan to help P6 understand the plan. See tag A-438.

4. Documentation for a Cognitive Therapy Group revealed P6's behavior as "Passive, Other: Passivity due to limited language proficiency". This indicated that even though P6 went to the group therapy, lack of interpreter services prevented P6 from participating in one of the goals of the treatment plan. While further review of documentation revealed that P6 attended "groups without prompting" and that group participation was met, no other group participation information was found in the record to indicate that P6 was provided an interpreter.

5. On day 3 of admission, a "Communication order" was written which stated in part, "Pt requires Spanish interpreter." Even after this physician order was written, no consistent interpreter services were documented.

6. Review of P6's education under "Barriers to Learning" revealed a documented response of "None Evident." P6 received education on day 2 and day 4 of admission with no evidence of interpreter services during the education.

While P6 was provided with some interpreter services, these were inconsistent throughout the record and meant that P6 was not able to consistently understand and participate in planning and treatment due to lack of interpreter services.

Physician documentation for P5 and P13 revealed that both were alert and oriented upon arrival to the ED. Physician evaluation indicated that both patients had capacity to make decisions and sign forms. However, both general consent forms for P5 and P13 were signed by surrogates where an incapacity must be determined prior to seeking surrogate consent.

Based on a review of patient #2's (P2) record, it was determined that facility staff failed to comply with patient's advanced directive and implement live-saving interventions when P2's heart stopped.

P2 was a 70+ year old patient who presented to the hospital in July 2018 with a chief complaint of weakness. P2 had cancer which had spread through P2's body. P2 was admitted to telemetry unit, and orders for telemetry monitoring were written with instructions to "Continue routine until discontinued." Telemetry monitoring included an alarm in case P1's blood pressure and pulse went outside parameters. P2 was Full Code on admission. Full code means that a patient wants clinical staff to perform all necessary life-saving interventions, such as chest compression, defibrillation, and insertion of a breathing tube, in case their heart stops.

On day 2 of admission, at P2's request, P2 was made Do Not Resuscitate (DNR) which disallowed the above-mentioned life-saving measures. However, no order was written to discontinue the telemetry and monitoring continued for two more days.

On day 4 of admission, the last telemetry reading was documented in the record. It was not known when P2 was removed from telemetry, but no other documentation of telemetry findings was identified in the record.

On day 6 of admission, P2 requested to be Full Code once again and the physician ordered the Full Code at 1330. Later that same day, P2 had an event which caused P2's heart to stop. No alarm sounded to indicate P2's failing cardiac status because P2 had been removed from telemetry. When P2 was found unresponsive, staff had to place P2 back on cardiac monitoring to confirm the death. The life-saving interventions that were desired by P2 and documented in the advanced directive were not implemented.

Facility staff failed to maintain ordered telemetry which could have alerted staff to P2's changing cardiac status and, as a result, failed to comply with P2's advanced directive for life-saving interventions.

Based on a review of two restraint records, it was determined that two of two restraint records lacked orders for the violent restraints for patient #3 (P3) and patient #7 (P7).

P3 was an adult who presented to the Emergency Department (ED) via police on emergency petition (EP) due to aggression in the community. P3 was placed into 4-point restraints at the time of presentation due to threats and fighting with police and was restrained for approximately four and a half hours. On P3's record review, no order for violent restraints was found.

P7 was an adult who presented to the ED via police on EP after being found asleep in the street while intoxicated. P7 was verbally threatening on presentation, and was placed into 4-point restraints. No order was found in the record for the one hour and 6 minutes of restraint time.

Therefore, P3 and P7 were restrained without physician orders to do so.

Based on review of two restraint records, it was determined that the facility failed to provide two out of two patients with a face-to-face assessment within one hour of initiation of the violent restraints.

Patient #3 (P3) was an adult who presented to the Emergency Department (ED) via police on emergency petition (EP) due to aggression in the community. P3 was placed into 4-point restraints at the time of presentation due to threats and fighting with police and remained restrained for approximately four and a half hours. While P3 was seen by the physician during this time, no face-to-face assessment related to restraints was found in the record.

P7 was an adult who presented to the ED via police on EP after being found asleep in the street while intoxicated. P7 was verbally threatening on presentation, and was placed into 4-point restraints for one hour and six minutes. No face-to-face assessment related to restraints was found in P7's record.

Based on review of documentation gathered on the Behavioral Health Unit (BHU) during an on-site unit review and later review of the full record provided by the hospital at the end of the survey for patient #6 (P6), it was determined that the facility failed to maintain accurate records for P6 as a new signature addition was noted on "Master Treatment Plan" in P6's record which was not present during the on-site review.

Documentation gathered on the BHU during an on-unit review on June 17, 2019 included the "Master Treatment Plan" from P6's record. This form contained signatures with dates and times from patient, psychiatrist, social worker, nurse, and recreational therapist. The form also had a place for "Other signature" which was blank. During the offsite review of P6's full record, a copy of the same form revealed the addition of a specific staff name, with the designation of "Interpreter" and without a date or time, on the "Other signature" line which had been blank.

Therefore, between the time of obtaining record copies on the unit and receiving the full record, an addition was made to the record which resulted in an inaccuracy.