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Based on a focused observation and review of a patient's medical record, an attempted interview of the patients by the surveyors and interviews of the licensed floor staff on 2/11/15 and 2/12/15, it was determined that not all patients were provided accurate language and communication assessments. In addition patients' language or communication needs were not identified, addressed, and individualized on their care plans. This was evident for 2 out of 11 sampled patient reviews.

Patient #2 is a 43 year old female who presented to the Emergency Department (ED) with a headache she had for three days. She also started to have chest pain on the date of admission 2/8/15. During her assessment and evaluation in the ED the physician and nurses identified the patient's primary language as Spanish and used the blue phone (Cyracom) to complete the assessments and evaluation. After the patient was transferred to unit 2200 (medical-surgical unit) on 2/8/15, the use of the interpretive phone was used sporadically and the care plan had no indication that the patient required use of interpretive services. Several notes in the patient's medical record revealed that some staff used the interpretive phone to complete their assessments and to obtain consent for testing. The bulk of the assessments did not document if the interpretive phone was used to communicate with the patient. After the patient had a seizure she was provided written information regarding her seizures in English by the physician. It was unclear whether patient #2 consistently received information via the interpretive phone to ensure that she fully understood information provided and to have her needs to provide informed consent.

Patient #9 was 91 years old and admitted on 02/11/15 from the Emergency Department (ED) to the hospital as an inpatient on the 3200 Unit. The patient's daughter accompanied the patient to the hospital and provided general patient information. The patient's admitting diagnosis was urinary tract infection and hematuria (blood in the urine). The patient's primary language is Vietnamese. The ED record indicated that the patient's preference for receipt of health information was not English. The review revealed that the ED Staff did not completely assess the patient's language (Vietnamese) status for the ability to understand and communicate in English. The ED communication assessment lacked any details about the patient's communication needs.


The night nurse, on the 3200 Unit, learned that the patient lacked the ability to understand and speak English. An Interview of the 3200 Charge Nurse for the 7:00 AM-7:00 PM shift on 02/12/15 at 10:15 AM revealed that she understood the patient was language challenged and spoke little English as reported by the night nurse to oncoming staff. While the night nurse passed this information to the day or oncoming shift, the night nurse failed to enter a note of assessment about the patient's interpretive language needs.


An interview of the patient's assigned day nurse on 02/12/15 at 10:58 AM revealed that she had learned through the report from the night nurse that the patient had a language barrier. The day nurse noted in a progress note that the blue language phones needed to be used when caring for the patient. Additional medical record this same day revealed that the communication section of the care plan was blank. The staff had not identified and addressed the patient's language needs on the care plan as of 11:00 AM on 02/12/15.


Failure to completely assess the patient's communication needs and to initiate and address the patient's communication needs on the care plan, potentially placed the patient at risk for: 1) not receiving clinical information in an understandable manner , 2) limited the patient's participation in decisions about his care including the development of a care plan, 3) having a delay in treatment because of a language barrier, and 4) creating potential to fragment the patient's continuity of care.

Based on staff interviews and the review of 11 medical records, in 1 of 11 medical records the hospital failed to ensure that the provision of care was in accordance with the fully informed consent of the patient as evidenced by: the patient's daughter and granddaughter were making decisions for the patient, including changes in medication and discharge planning, without any documented consent of the patient.

Patient #1 is a 91 year old female who presented to the Emergency Department at Adventist HealthCare Washington Adventist Hospital with complaint of having abdominal pain due to gas. She reported taking gas-x without relief. The patient was alert and oriented x4. She was admitted on 1/17/15 with differential diagnoses abdominal pain, urinary tract infection, pyelonephritis, peptic ulcer disease, gastritis, and constipation. The patient's other diagnoses included arthritis, hypertension, diverticulosis of intestine, thrombocytosis, glaucoma, platelet disorder and end-stage renal disease (ESRD), and Methicillen Resistant Staphylococcus aureus infection (MRSA). After her work-up the patient was diagnosed with small bowel obstruction requiring surgery.


According to her medical record patient #1 was alert and oriented x4 with a period of delirium for several days while in ICU. There was no documentation in the medical record that patient #1 lacked capacity. The patient signed forms for consent to treat, financial forms and consents for surgery. At discharge the MOLST form revealed she was a full code and that the physician discussed the orders with the patient. No surrogate healthcare decision makers were identified in the document. However, there was documentation in her medical record stating that patient #1 was independent and that she had a granddaughter in Florida who was responsible for her care and to make decisions about her healthcare as stated in a progress note by the health nurse on 1/20/15 at 12:08 PM as well as notes by the physicians, nursing and social work/case management. Patient #1's granddaughter from Florida submitted a durable power of attorney (DPOA), signed and dated by the patient on 1/23/15 and notarized on 1/26/15. The DPOA addressed primarily financial issues except under restrictions on agent's powers (5) which stated "cannot contravene (contrary or opposite) any medical power of attorney I have executed whether prior or subsequent to the execution of the Power of Attorney." There was no documentation in Patient #1's medical record of an advance directive or healthcare directive that was initiated by the patient prior to her admission to the hospital on 1/17/15. On 1/30/15 at 12:00 AM, the patient was described as alert and oriented x4 and able to follow commands. On the same date at 5:15 PM Patient #1's granddaughter in Florida expressed concerns over the fact that patient #1 had MRSA in the nares and that she was on Xeralto. The note read in part "she (granddaughter) wants the Xeralto discontinued and the patient started on Lovenox 40mg. The RN will follow-up with nursing concerns and physician called aware of the medical issues." The physician stated she was aware of the concerns and will discontinue Xeralto and will call the granddaughter in Florida. This progress note as well as others reveal the hospital making changes in the patient's treatment based on Patient #1's granddaughter's wishes rather than those of the patient who was not identified at the time as lacking capacity to make her decisions nor was there documentation that the patient had agreed to her granddaughter making her decisions.

The hospital failed to protect patient #1's right to make her health care decisions and instead deferred to granddaughter to make these decisions including medication changes and discharge plans.

Based on interview and review of facility documents for maintenance and repairs, it was determined that the facility staff failed to provide maintenance and repairs necessary to maintain adequate hot water for the facility.

On 2/12/15, in response to a complaint of no hot water in a patient's room in January 2015, the surveyor requested information from facility staff concerning maintenance and repairs of the hot water system for the building. The initial readings below 100 degrees Fahrenheit were recorded on 11/10/14. A written timeline provided by the director of facilities stated that the domestic hot water issue was first identified on 12/15/14 as a result of staff phone calls about a lack of hot water. Final repairs were completed on 1/26/15. At the time of the survey on 2/12/15 additional water heating system that had been abandoned for use in the facility was being repaired. An interview of the director of facilities revealed that there were no records available for preventative maintenance for the system, but a system for checking and cleaning the equipment was being initiated immediately. Review of the vendor's repair records indicated that the copper tubing that moves water through a heating system was blocked. The blockage was so severe that the tubing could not be cleaned and had to be replaced.


Review of the hot water records provided for eight dates between 1/3/14 and 2/2/15 revealed that hot water was not available in the following areas on the dates tested:
50 Building: Three of eight readings were below 100 degrees Fahrenheit (F).

70 Building: Four of eight readings were below 100 degrees F. These readings were taken in the surgery unit.

80 Building: Five of eight readings were below 100 degrees F. These readings were taken in the medical records unit.

90 Building: Three of eight readings were below 100 degrees F. These readings were taken in the emergency department.

Dietary: Two of eight readings were below 100 degrees F.

Review of the hot water sanitization records for the dishwasher in the main kitchen revealed that during December 2014, January 2015 and February 2015 for fifty three meals no water temperatures were recorded for the dishwasher. For the additional 169 meals served during the period reviewed forty nine were recorded as meeting the final rinse temperature of 180 degrees F. This requirement ensures that dishes are adequately sanitized. An interview of the director of nutrition services at 8:00 AM on 2/12/15 revealed that he hand sanitized dishes as needed when the dishwasher temperatures were inadequate. Additionally, when possible, he used disposable dishes and utensils. He stated that he did not have written evidence of this hand sanitizing procedure. He did not provide evidence of a protocol for staff to know when to hand sanitize dishes.