HospitalInspections.org

Based on review of hospital policies, 8 open and 5 closed medical records, it was determined the hospital failed to uphold two patients' rights to being informed and involved in their care and treatment by 1) failing to provide adequate or timely interpreter services for patients #2 and #3; and 2) failing to certify an incapacity for patient #3 prior to obtaining consents from a surrogate.

Per hospital policy titled "Interpretation and Translation Services: Patient Language and communication Needs" (Effective 01/01/19), "Should the patient insist upon the use of Family/Friends ...to provide Interpretation services, 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."

Patient #2 was an 80 + year old Korean speaking patient who presented to the hospital for altered mental status. Patient #2 was admitted to the hospital for further management and treatment of dehydration. Per provider admission history and physical, the patient was "responding well and [became] awake and alert after receiving IV fluids in the ED." There was no indication an interpreter was used during this encounter.

On the patient's second day per "language/ interpreter/ communications need identified" assessment "Patient/ Family/ Friend Declined Services." There was no indication in the record on how the nurse established this baseline declination of interpreter services without obtaining baseline interpreter services.

A notice for Observation status in English was also found in the chart dated the day patient #2 presented to the hospital. There was no indication that an interpreter was used to explain the notice.

Patient #3 was an 80+ patient who presented to the emergency department (ED) in October 2018 with abdominal pain. A nursing note in the ED of 1725 stated in part, "Pt Korean speaking only (with history) dementia. Pt's history obtained from pt's (family member)." An RN note of 2110 revealed in part, "Pt's (family member) pt more alert, able to speak, but reports is slower to respond and still seems more confused than (Patient #3's) baseline. Pt currently oriented to name and place only."
This meant that when patient #3 improved to a point of speaking, no interpreter services were obtained to actually assess patient #3's mental status, and to establish if patient #3 wanted a family member to interpret.

A History & Physical of 2148 stated in part, "History provided by (family member) ...and, (per the history some days prior), "mental status gradually improved closer but still not at (patient #3) usual baseline ..." All information regarding patient #3's mental status was obtained from family, and was not confirmed by an assessment augmented by a certified interpreter.

Review of hospital policy "Informed Consent" (Effective 01/01/2019) revealed in part, " ...A Surrogate Decision Maker may make decisions about health care for a person who have been certified by two (2) Maryland licensed physicians as being incapable of making medical decisions ..."

On day two of presentation, a consult documented in part, " ...The information that we have received came from (patient #3's family member) because the patient is an elderly woman, who has dementia and she is Korean speaking only and therefore the information was provided by (family member)..." This meant that without an interpreter by which to assist in actually assessing patient #3's mental status, an assumption was made that patient #3 could not participate in patient #3's care. However, no certification of incapacity was found in the record. In fact, no interpreter was ever obtained to determine if patient #3 lacked capacity to make medical decisions prior to going to the family member/ surrogate for decision-making.

Consents inclusive of blood, anesthesia, and other procedures were signed by a family member/surrogate though no incapacity was ever certified.

In summary, the hospital failed to provide interpreter services for patients #2 and #3 to establish baselines regarding #2 and #3's desire for interpreter services, to assist with accurate assessments, to determine mental status related to capacity, and to augment participation in care to whatever degree possible. Therefore, the hospital failed to uphold the patient's right to make informed decisions regarding his or her care.

Based on review of hospital policy, staff interviews, 5 closed records and 8 open records, it was determined the hospital failed to document and reassess patient #1 as per hospital policy in the emergency department (ED). In addition, it was determined that the hospital failed to demonstrate that patient # 5 medical record provided an accurate and timely reflection of family notification, patient care, and staff roles and responsibilities during hospitalization.

Per hospital policy titled, "Assessment of Emergency Patients" (11/18), "Ongoing assessments, pain level, response to therapy, independent and dependent nursing functions, patient teaching, significant changes in condition are documented as needed, at a minimum of every 4 hours." In addition, per interview with ED manager while touring the ED, it was stated the expectation for staff was to assess patients' every 2 hours.

Patient #1 was a 60+ year old who presented to the hospital's emergency department with a chief complaint of confusion and disorientation at 16:58. Patient was triaged at 17:03. Triage vitals showed an elevated blood pressure of 202/89. The Emergency Severity Index was documented as level 2, a level given for patients who are at high risk for deterioration. A rapid exam by a provider was conducted at 17:04, patient #1 was documented to be alert and oriented x3.

Diagnostic testing was ordered and performed in a timely manner. The CT resulted at 18:13 and was negative. Per plan of care documentation at 2217, next to "waiting explained," "The family was informed of the patient's status. Patient was roomed at 01:07 and seen by the ED provider at 02:27, no focal neuro deficits" were noted. Around 02:50 patient received medication.

Another set of vitals was not done until 03:19. The final ED diagnosis was memory loss and transient ischemic attack. Patient #1 was admitted to observation status for further monitoring.

Based on all documentation, no new assessment and vitals were taken for an approximate 10 hour period which failed to meet both the standard of care and hospital policy.

Patient # 5 was a 90+year old who presented to the hospital ' s emergency department with shortness of breath, even with home oxygen supply. During the six-day hospitalization the patient's condition declined and the option for palliative and/or hospice care was agreed upon by the family. The patient was awaiting evaluation and acceptance by the hospice provider when the patient expired sometime overnight. The last set of vital signs were documented 12 hour prior to being found.

Nurse #1 entered a night shift note at 0733, "patient was unresponsive at 0700. MD on call called to check the patient and call the family. . .." A note from day shift nurse #2 at 1304 noted "Assumed care of the patient at 0700. Prior to assuming care patient was found unresponsive and had been pronounced dead." This note, written 6 hours after the patient had been found also indicates that "MD provided bereavement support" ....and includes details on the post mortem care. Nursing and physician documentation made it impossible to determine when patient #5 died.

The two above mentioned and other accounts in the medical record reflect disparities in the notification of family to patient's death, care provided pre & post mortem, and staff roles and responsibilities for a dying and dead patient. Per family report and review of pertinent hospital documents the family arrived to visit at 1000 and found the patient in bed deceased, no clinical staff was present in the room. According to the family, clinical staff failed to inform them of the patient's death prior to their arrival at the hospital.The family alleges that the patient was not cleaned and had to request for post mortem care to be done.

The medical record documentation of the death of the patient was sparse, lacking completed flowsheets for death reporting and no indication of notification of the organ procurement organization. Nursing and physician documentation made it impossible to determine when patient #5 died and when the family was notified of the death.

In summary, the hospital failed to inform the patient's family that the patient had died overnight and the medical record had limited and contradictory accounts of the care provided to the patient once expired.