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Based on interviews, review of the patient record and hospital policy, the hospital failed to obtain appropriate interpreter services to communicate with patient #2 from admission and for seven days following admission; failed to identify if patient #2 desired a healthcare agent; failed to identify a specific healthcare agent, failed to inform patient #1 of the severity of her condition, and consequently, failed to obtain informed consents from patient #2.

Patient #2 is a 66-year-old, Spanish speaking female from Peru. Patient #2, who lives with her husband, arrived emergently and alone to the hospital emergency department (ED) on 1/13/2010 with complaints of an eight-day recent history of fever, malaise, weakness and cough. Patient #2's medical history included status post gallbladder surgery, chronic hepatitis B with cirrhosis and coagulopathy, portal hypertension, varices with ligation (two years prior), and asthma.

Based on a review of the hospital's Patient Rights Policy approved 5/2/2008, it states in part that a patient has the right to:
1. An interpreter by verbal, written or signed communication when you do not speak the predominant language of the community.
2. Complete information about your illness, possible treatments and likely outcomes, and the chance to discuss this information with your physician.
3. Appoint a healthcare agent to speak on your behalf if you lose the ability to communicate your wishes regarding possible treatment alternatives, and to expect that your advance directives will be followed. For more information ...
4. Be told of realistic care alternatives when hospital care is no longer appropriate.


A review of the patient's medical records revealed an ED nursing note of 1/13 at 7:31 pm which states, " Pt. Spanish speaking only. Family on the way to the ED." The physician examination noted patient #2 to be alert and oriented to 3 spheres, with an appropriate mood and manner. No other nursing or physician notes in the ED refer to patient #2's language barrier, nor does it document how staff were informing patient #2 of her status. There is no ED documentation that indicates patient #2 requested a family member to be her spokesperson.

Patient #2 was admitted in fair condition with a physician impression of pneumonia, fever, hepatitis with increased bilirubin, and decreased platelets.

The initial nursing assessment of 1/13/2010 identifies patient #2 's Readiness to Learn as "Cooperative, calm," Barriers as "Language," Language as "Spanish," and "Interpreter needed." there is no documentation that interpreter services were obtained for patient #2 over the ensuing week of treatment, nor did patient #2 receive interpreter services in order to designate a healthcare agent. Based on a review of hospital policy "Communication Services for Patients, " it was revealed that a patient may sign a "Patient waiver of Interpreter Services" when wanting to use their own interpreter. No waiver is found in the medical record of patient #2.

A hematology consultation of 1/15/2010 states in part, " .....Most of her history was obtained through her husband who speaks English. She is only fluent in Spanish." The physician documented a thrombus in the portal vein and borderline coagulopathy, secondary to liver dysfunction. He states "I have discussed this in extensive detail with the husband and I noted to him that this may not be in our hands, but may be in God's hands" and " .....At some point or another, in the near future, we may need to talk with the Palliative Care Committee about Hospice placement. Certainly, if this thrombus gets worse or moves, it will cause sudden liver failure that will be irreparable and will ultimately spell her demise in short order."

On 1/19/2010, a Hospice representative documented on the Consult Summary: Liasion Visit. She wrote, "Discussion with pt's (Son #1) regarding Hospice Services & Philosophy. At this time, the pt. wants " to fight" and the son is worried about talking to her about her terminal condition. He will speak with his brothers tonight to decide if Hospice is desired at home. (Son #1) wants comfort care, understands there is not any treatment for cure ... "

There is no concurrent hospital documentation to indicate that patient #2 was informed of her terminal condition or on what information patient #2's was basing her desire "To fight." Son #1 expressed his concern of being an interpreter for this sensitive information and consequently, it is unclear what information was conveyed.

On 1/20, the Hospice representative met with (Son #1) again. She documents that "He continues to have questions about care of his mother in the home. He would like to meet with his brother, Hospice and Dr._____. It was explained to him that Dr. _____ is probably unavailable and a discharge plan could be made without him. Will meet with family at 11:30 am on 1/21/2010 to attempt to develop discharge plans." The representative then documented under Other Information/Concerns/Issues " Pt. needs to give consent either to allow her family (sons) to make medical decisions or be informed & give consent to Hospice care. Will address this on 1/21/2010."

Social worker notes of 1/20 at 2:06 pm state in part "Pt. also needs to consent for hospice care or determine which son has the power to sign on pt. behalf."

Social worker notes of 1/21 at 2:34 pm state, " Social worker had a long discussion w/pt. son (Son #2) regarding d/c home today w/hospice ... " and "The sw (social worker) informed that (Son #2) will be the primary caregiver and family will assist when available ... " and " Son #2 states pt. (patient) husband will sign consent forms for hospice care at home."

A social worker interview on 1/21 and 1/22 reveals that the husband and sons of patient #2 were the only translators during the preceding week of care. A translation service called Language Line was brought in on 12/20 to obtain hospice consents that patient #2 had not signed. Patient #2 did not at that time accept Language Line. The social worker states she " Shook her head, and kept her eyes closed." At that point, patient #2's husband stated "Talk to me."

The social worker went on to state " The family leaves the room dark, and the patient won't socialize." She stated that the physician spoke with one son on Tuesday, and the sons did not want the word "Hospice" stated to their mother. In addition, the social worker states that patient #2 "Waved staff off, and would not talk with staff." Another son flew in from Peru to help with decision-making. The social worker states that no decisions were made without the husband and that patient #2's husband signed the consent for Hospice following discharge.

Patient #2 was assessed as oriented and cooperative on admission, yet there were no documented efforts to obtain translation services. There is also no hospital documentation to indicate that patient #2 lacked capacity to make informed decisions. Further there is documented evidence that patient #2 requested and identified a healthcare agent or surrogate. After 7 days of hospitalization, the record indicates that the hospital brought in an interpreter only after needing consent for hospice or the identification of a health care agent.

In the absence of obtaining an interpreter to accurately and consistently inform patient #2, the hospital used at least 3 family members to inform patient #2 of sensitive issues related to her condition, treatment and ultimately, the futility of care. Documentation indicates that family members, verbalized "Worry" about informing patient #2 of her condition and did not want the term "Hospice" stated to patient #2.

Consequently, during the admission of patient #2, the hospital could not know the quantity or quality of the healthcare information given to patient #2 through her sons and husband. During seven days of care, the hospital once attempted to obtain translation services, but patient #2 was no longer as cooperative as she had been on admission.

Based on interviews, review of the patient record and hospital policy and procedure, it is determined that during her hospitalization, patient #1, who was admitted as Do Not Resuscitate (DNR), requested a Full Code status. The hospital initially facilitated this change, but changed patient #1 back to DNR based on the wishes of the Power of Attorney (POA).

Patient #1 is an 89-year-old female who came to the emergency department (ED) on 12/24/2009 from an assisted living facility (ALF) due to weakness and fatigue following routine blood work at her physician office that showed a marked drop in hemoglobin (6.7). Patient #1 has a past medical history of chronic kidney disease, diabetes mellitus, B12 deficiency, Vitamin D deficiency, severe degenerative joint disease, glaucoma, hyperlipidemia, and cardiac murmur. Patient #1 had recent agitation and dementia treated with low doses of seroquel and haldol, and ongoing inflammation of the eyes, followed by ophthalmology.

A History and Physical of 12/24/2009 at 1:34, transcribed by the same physician who attended patient #1 at the ALF states " The patient has been DNR in the past and has refused dialysis or major surgeries." The physician's progress note of 12/24 states "Pt. is known to me, sent to (hospital ER) because of sudden fall in___ 12-7." The end of the note states "Conservative - DNR."

A review of systems revealed "Significant for progressive edema, weakness and episodes of agitation. The patient also has been experiencing arthralgias, myalgias, and slight agitation." The physician states in part "No sensory or motor deficits. The patient can move all of her extremities in response to tactile stimulation. The patient, however, is very lethargic and does not respond to conversation." Patient #1's treatment plan included "CT (computed tomography) scan of the brain for workup of the encephalopathy will be requested" and "The patient's code status will continue as DNR and invasive procedures will be avoided in consideration of the patient's previous request." Orders written on 10/6/2009 while patient #1 was in the assisted living indicate patient #1 was "DNR, no code blue."

Based on review of the hospital's patient rights handbook, it states "You have a right to appoint a healthcare agent to speak on your behalf if you lose the ability to communicate your wishes regarding possible treatment alternatives, and to expect that your advance directives will be followed ..... " Two of patient #1's children share the duties and obligations of a durable power of attorney (DPOA) though patient #1 has at least one other child as well.

On the evening of 12/26/2009, at approximately 10-10:30 pm, a daughter who did not have power of attorney and a Granddaughter visited patient #1 and noted the DNR bracelet on her wrist. An RN #1 note of 10:29 pm reveals "Pt alert and oriented x 3. More oriented than before. Daughter talked to Pt and pt refused being DNR, stating she will like the nurses and doctors to do everything possible to bring her back to life should her heart stop to beat. Unable to get hold of (daughter POA). ____(Son) who is also POA consulted. Dr. ____ notified and PT code status changed to Full Code per order." Subsequent to RN #1's call, a telephone order for full code appears in the record at 10:55 pm.

Interview with the RN #1 on 2/12/2010 at 9 am reveals that after calling the son with the POA, he came to the hospital and stated that if that is what my mother wants, then it was all right with him. The RN reports that during the decision-making, there was no emotional upset demonstrated by the daughter without the POA or patient #1. The RN states that patient #1 was fully oriented at the time of her request, and that patient #1 stated that she did not remember ever having asked to be DNR.

On 12/30/2009 at what appears to be a 9 pm order, the physician writes "Patient is DNR, no code blue. Arrange transfer to (ALF) 12/31/2009 evening or PM." An untimed physician note dated 12/30/09 states in part "DNR was reaffirmed, will note." There is no documentation on the records of physician capacity statements indicating that patient #1 was assessed for, and lacked capacity to make her own healthcare decisions. Patient #1 was discharged back to the ALF on 12/31/2009.

When the risk manager was questioned and interviewed, she stated that the attending physician stated that he knew patient #1 from the nursing home (ALF) and that she was confused, and had end stage renal failure with encephalopathy. He stated that patient #1 had spoken to him previously about her wishes not to have extraordinary measures, dialysis, things of that nature and that she wanted to have DNR status. He stated that one of the children visited the patient, upset patient #1 and insisted her resuscitation status be changed.

The physician states that "The nurse called me late in the evening about this and I told her we would change her to full code until we could sort it out. The next day I clarified with the POA son about her code status and it was changed back to DNR." The physician went on to state "Since that time she passed away at the nursing home."

Upon admission to the hospital, patient #1 had an advance directive for DNR. While receiving care, patient #1 verbalized a new advance directive given at a time when she was alert, oriented, and able to state her wishes. The hospital initially followed the new directive by way of orders for Full code status. Following orders for Full code status, the physician wrote a DNR order without a new directive from patient #1 or physician statements of capacity. The hospital had a responsibility to follow patient #1's new advance directive of Full Code or indicate by way of capacity statements, that patient #1 no longer had the capacity to make health care decisions.