HospitalInspections.org

Based on review of hospital policies and 7 open and 10 closed medical records, it was determined the hospital failed to uphold the patients' right to being informed and involved in their care and treatment by not providing adequate interpreter services for patient 5; and failed to assess whether patient #6 lacked decision making capacity or certify an incapacity prior to changing patient #6's code status.

Per hospital policy titled "Language Interpreter and Translation Services" (Effective date 04/18/2017) "If the patient refuses the services and insists that a friend or relative act as an interpreter, the patient will be advised that the hospital will utilize a language interpreter to confirm the patient's wishes to have a family member interpret."

Patient #5 was a 75+ year old Spanish speaking patient who presented to the hospital with abdominal pain around midnight. After initial evaluation and treatment in the emergency department, patient was ordered to be admitted around 02:28. Per the provider's initial assessment at 03:30 (Admission History and Physical), it was documented: "Translation Services: Family member by patient preference." There was no indication in the record how the provider established this baseline or how they knew this to be true without obtaining an interpreter. In addition, there was a surgical physician assistant progress note at 17:00 that did not mention the use of an interpreter.

A notice for Observation status in English was also found in the chart dated the day patient #5 presented to the hospital. There was no indication that an interpreter was used to explain the notice or a note on why a family member signed the form and not the patient as patient #5 was alert and oriented.

Per hospital policy titled, "Informed Consent" (effective date 07/28/2017) section F. "Surrogate Decision Making," "7. Certificate of Incapacity" "a. Prior to providing, withholding or withdrawing treatment or procedures on the basis of surrogate decision making, the attending physician and a second physician ....shall certify in writing that the patient is incapable of making and informed decision regarding the treatment."

Patient #6 was a 95+ year old patient who was admitted to the hospital for altered mental status and failure to thrive. Patient #6's code status was changed on the third day of admission from "full code" to "No CPR- Palliative and Supportive Care" around 10:00. Per provider progress note, the decision was made by the patient's offspring. At time of record review by surveyor while onsite around 10:30, there was no documentation found in the record of a certification of incapacity by a provider prior to the code status change. At the end of the survey day, a document was presented titled "Documentation of Patient Decision Making Capacity." Under section III. "Communicative Patient Lacks Decision Making Capacity" was signed by two physicians as appropriate at 1350 and 1345, however, this occurred after the code decision was made.

In summary, the hospital failed to obtain interpretive services for interactions involving patient #5's care and treatment and failed to uphold patient #6's right to make informed decisions regarding his or her care.

Based on interview, review of job descriptions, requests for training and policies, it was determined that the hospital failed to provide health care restraint training for off duty police officers (ODPO) subject to clinical oversight; and failed to provide a Use of Force policy or guidance related to the use or retention of law enforcement weaponry by the ODPO.

Review of the "Secondary Employer Agreement for Security Related Work" a document originated by community police stated in part, "It is agreed that the following stipulation will apply to all off duty employment of (County) Department of Police employees in watchman security guard capabilities" ...."5. The secondary employer will make no attempts to exert any influence regarding a police decision involving whether an arrest should be made."

This meant that while working as a part-time employee for the hospital, and without clinical decision-making, the police officer had free agency to determine the removal of any person, including patients presenting for or receiving care.

An orientation manual for the county police documented in part, "Assisting Hospital Security Staff - it is expected that on the rear (sic) occasion that hospital Security staff requests assistance/back up that the assigned (county) Off Duty Officer will arrive and render assistance in a timely manner." "Back up" meant in part that the ODPO might be assisting to restrain persons, including patients. However, the hospital failed to offer the ODPO healthcare restraint training in techniques that could be subject to clinical oversight.

Additionally, a provision of the ODPO orientation was documented as, "Police Officer will be proficient in de-escalation techniques: Apply sound judgement in the enforcement of hospital rules and regulations and applicable State laws necessary for the protection of persons and property; physically apprehend and control patients or law violators for their safety until on-duty units arrive; ...work closely with medical and nursing staff to resolve patient-related problems ..."

While the hospital stated expectations of ODPO compliance, the hospital never actually gave the ODPO's training by which to comply. Interview with one ODPO on 1/15/2019 at approximately 1030 revealed that ODPO's receive their own training from their police departments in the application of forensic restraints, but no training from the hospital in the use of restraints in a therapeutic environment.

Further interview revealed that the ODPO carried police weapons such as a gun, baton, pepper spray and handcuffs. A request of hospital administrators for a Use of Force policy or other guidance related to the use of police weapons within the hospital and grounds revealed no such guidance existed at the time of survey. This meant that the ODPO had free agency to determine when and how to use police weapons within the hospital.

In summary, the hospital failed to provide appropriate training, oversight and instruction of employed ODPO's related to multiple expectations and support requirements within the hospital.