HospitalInspections.org

Based on review of 12 medical records and hospital policies and procedures, the hospital failed to include 1 of 12 patients in planning and implementation of care, as evidenced by failure to notify Patient #1 (P1) with limited English proficiency and their family member of P1's acceptance and transfer to a skilled nursing facility (SNF) prior to discharge.

Surveyors reviewed the hospital policy titled "Interpretation and Translation Services: Patient Language and Communication Needs" (dated 1/1/2019) which stated: "The Participating Organization, outside of the circumstances described below, prohibits individuals who require Language Services for Medical Discussion, including individuals wo are Deaf/Hard of Hearing, to use Family/Friends as interpreters or supply a personally-contracted interpreter.

a. When there is an imminent threat to the safety and welfare of the patient, designated workforce members may rely upon an adult Family/Friend, patient-supplied interpreter, or a minor, while waiting for a Qualified Interpreter through one of the three Interpretation Modalities (OPI, VRI, IPI).
b. Should the patient insist upon the use of Family/Friends or a patient-supplied interpreter to provide Interpretation service, designated workforce members shall retain a Qualified Interpreter to participate in the communication exchange to ensure accurate transmission of information between the workforce member and the patient and Family/Friends.
c. These circumstances shall be documented in the patient's EHR. [Electronic Health Record]"

P1 was an 80+ year old with limited English proficiency who was admitted to the hospital after a sustained fall with an injury that required a surgical intervention. Review of P1's medical record determined that P1's family member was actively involved in care planning for P1, often assisted with translation between P1 and clinical staff, per P1's request, and was in communication with hospital discharge planners regarding P1's post-hospital care. (See tag A-0131 for a related Informed Consent deficiency). The discharge plan was developed for P1 to be transferred to a SNF for rehabilitation after hospitalization.

Throughout P1's admission, the hospital discharge planners documented frequent communication with P1's family member regarding choices for SNF placement, touring various facilities, and selecting a SNF for P1 to be transferred to at the time of discharge. There were documented modifications to P1's discharge plan due to changes in P1's health care needs. Medical record documentation reflected that P1's family member was made aware of said changes.

On the day when P1 was discharged to a SNF, the hospital discharge planner documented P1's acceptance to a SNF and transportation arrangements made for discharge. The discharge planner failed to document notification given to P1's family member regarding P1's acceptance into the SNF, and P1's tentative discharge date or time. As a result, P1 was transported to the SNF without P1's family member being aware of the discharge.

The lack of notification to P1's family member regarding the name of the SNF, date, and time of discharge prevented P1's family member, and ultimately P1 due to limited English proficiency, from participating in effective transition of care and discharge planning for P1.

Based on review of 12 medical records and hospital policies and procedures, the facility failed to allow 1 of 12 patients to make informed decisions about their care, as evidenced by failure to provide interpreter services for Patient #1 (P1) which would enable P1 to give informed consent, allow the patient the right to refuse or request treatments, to establish a baseline including a medical history or to determine P1's understanding of the discharge instructions.

Surveyors review the hospital policy titled "Interpretation and Translation Services: Patient Language and Communication Needs" (dated 1/1/2019) which stated: "The Participating Organization, outside of the circumstances described below, prohibits individuals who require Language Services for Medical Discussion, including individuals wo are Deaf/Hard of Hearing, to use Family/Friends as interpreters or supply a personally-contracted interpreter.

a. When there is an imminent threat to the safety and welfare of the patient, designated workforce members may rely upon an adult Family/Friend, patient-supplied interpreter, or a minor, while waiting for a Qualified Interpreter through one of the three Interpretation Modalities (OPI, VRI, IPI).
b. Should the patient insist upon the use of Family/Friends or a patient-supplied interpreter to provide Interpretation service, designated workforce members shall retain a Qualified Interpreter to participate in the communication exchange to ensure accurate transmission of information between the workforce member and the patient and Family/Friends.
c. These circumstances shall be documented in the patient's EHR. [Electronic Health Record]"

P1 was an 80+ year old who was admitted to the hospital after a sustained fall with injury that required a surgical intervention. Documentation review determined that P1 was alert and oriented during the admission. P1 was also identified to need interpreter services due to non-English proficiency.

P1 received care on three separate nursing units, while admitted to the hospital. Hospital staff documented the use of a hospital-provided interpreter service upon admission, and day two of admission during P1's 10-day inpatient visit.

A critical care progress note on day three of P1's stay, written by the provider who assessed P1's neurological status as "Awake [w]ith eyes open, nodding and speaking (though limited 2/2 to language) seemingly appropriate." No documentation was found that certified interpreter services were called or accessed at that time to assess P1's true neurological status.

Review of a Physical Therapist (PT) initial assessment note on day four of P1's hospital stay identified no language/ interpreter/ communication needs. Conversely, an Occupational Therapist (OT) note the following date did identify language/ interpreter/ communication needs. The OT further noted, "Patient [P1] and patient's [P1's family member] preferred patient's [P1's family member] to interpret.) There was no documentation of a facility provided interpreter being utilized to verify the accuracy of the information exchanged.

On day 5 of P1's admission, immediately after transfer to a new nursing unit, the documentation noted that P1 was in pain and became inconsolable. The nursing documented also noted, "This nurse called [P1's family member] in
hopes to get [P1] to calm down. [P1] continues to yell out. Unable to settle [P1] due to language barrier. [doctor] aware of situation." There was no documentation found in the medical record to show that the staff accessed interpreter services to communicate with P1 during P1's distress, or to accurately assess P1 after initially arriving to that nursing unit.

In summary, the hospital failed to obtain interpretive services for numerous interactions involving P1, including to verify the exchange of information between P1 and their family member who provided interpretation services. In doing so, the hospital failed to allow P1 to be an active participant in their treatment and care due to ongoing language barriers.

Based on review of restraint and seclusion records for 2 pediatric patients and policies and procedures, it was determined that the hospital failed to ensure that 2 of 2 pediatric patients were properly assessed by a physician within the first hour of being restrained, as evidenced by the lack of documented face-to- face assessments in the medical records for the reviewed restraint episodes.

Surveyors reviewed the hospital policy titled "Restraints and Seclusion" which stated in part ...."A documented face to face evaluation must be completed within one hour of initiating the restraint and at least once every 24 hours by a physician responsible for the ongoing care of the patient prior to ordering a restraint or seclusion."

P2 was a 15+ year old patient who presented to the emergency department (ED) for a mental health evaluation after being found to be disoriented with incoherent speech. P2 was noted in the medical record to be ..."combative and violent, kicking, thrashing, and attempting to flee." P2 was placed into four point restraints for aggressive behavior for a total of 4 hours, which included the restraints being renewed after two hours.

The provider ordered the restraints at 11:22 a.m. The restraints were initiated at 11:25 a.m. The provider completed a face-to-face evaluation of the patient at 11:15 a.m. The face-to-face assessment was completed 10 minutes before the patient was placed into restraints, not within one hour of restraint initiation, as required.

Patient#8 (P8) was a 15+ year old patient who was brought to the ED in the fall of 2019 for a psychiatric evaluation due to bizarre and aggressive behavior. On arrival to the ED, P8 displayed aggressive behavior, became combative, and required an emergency intervention, including a physical hold and administration of chemical restraints. Nursing documentation was reviewed and provided details surrounding the restraint episode. However, no physician note or required face-to-face assessment within one hour was found in P8's record for this restraint episode.

The hospital failed to ensure that P2 and P8 were assessed within an hour of restraint initiation by a physician and required documentation was completed. Without an appropriate face-to-face assessment within an hour of the intervention, it was unclear if other redirection attempts were made for P2 and P8 immediately prior to the restraints that did not work, what the patients' response to the interventions was, and whether there was a need to continue the restraints.

Based on review of the closed medical record of three emergency department (ED) visits for one pediatric patient, policies and procedures, and Medical Staff Rules and Regulations, as well as an informal interview with staff, it was determined that the hospital failed to ensure that 2 of the 3 ED visits contained a discharge summary and/or transfer summary of the patient's hospital visit.

Pt #8 (P8) was a 15+ year old patient who presented to the ED twice on the same summer evening in 2019. P8's first visit was at 6:43 pm for behavior changes. The patient was seen and assessed by a pediatrician and the Crisis Intervention Specialist. During this visit, the decision was made that P8 did not meet criteria for inpatient admission. Outpatient resources were provided by ED staff, and P8 was discharged with their guardian just before 2:00 am the following morning.

The second visit occurred just over an hour after the first discharge. P8 was brought back to the ED at 3:18 am by the local law enforcement, after P8 told officers, "I don't want to be sacrificed by the devil". P8 was assessed again by the ED staff and, based on new information, a recommendation was made for an inpatient admission. P8 remained in the ED for three additional days, while awaiting inpatient placement. On day 4, P8 was transferred to a hospital with capability to meet pediatric psychiatric needs.

The third visit occurred during the fall of the same year, when P8 was brought to the ED for a psychiatric evaluation due to bizarre and aggressive behavior. During this visit, P8 displayed aggressive behavior, became combative, and required emergency interventions, including use of restraints. P8 was eventually transferred to another facility capable of meeting P8's needs for inpatient psychiatric treatment.

Review of documentation for the above-mentioned visits revealed lack of discharge summaries for all three visits. When the hospital staff assisting surveyors during the chart review were asked about the lack of discharge/transfer summary within the medical record, the staff reported that a discharge summary was not required for all patients. The staff also noted that the hospital's practice was not to require a discharge summary in the medical record for patients with less than 2-day hospitalization. Staff indicated that this was documented in the hospital's policy and referred surveyors to the Medical Staff Rules and Regulation.

Review of the Medical Staff Rules & Regulations (approved by Board of Trustees 05/02/2016) revealed in part: "Section 4.9. A discharge summary shall be written or dictated for all patients who are hospitalized for more than two (2) days or expired. A final progress note containing the outcome of hospitalization, disposition of the case and provisions for follow-up care may be substituted for the discharge summary for hospitalizations of two (2) days or less."

Additional review of P8's medical record was conducted and determined the Final Progress Note from P8's first and second ED visit did not meet requirements outlined in this regulation or the hospital provision, as both lacked documented disposition for P8. The Final Progress Note for the third ED visit was found to meet the regulatory requirements; however, it was noted that the critical details of the patient's hospitalization were lacking.

In summary, the hospital failed to ensure that the medical staff maintained a complete medical record for each patient and documented required components, such as discharge summary.