HospitalInspections.org

Based on interviews, observation, review of the medical record, policies, procedures and other pertinent documentation, it is revealed that a Spanish-speaking patient received no translation services with which to paticipate in hospital treatment.

Patient #9 is a 31-year-old Hispanic female admitted from 11/27/2009 to 12/1/2009 through the emergency department (ED) following complains of a 2-week history of increasing right flank pain, and fever of 103.5. Patient #9 was hypotensive on admission (80/40) but responded somewhat to IV hydration. The physician history and physical (H & P) states that "History provided by ER staff, as the patient is Hispanic and does not speak English, and she does not have any family at this time. Past medical history negative per ER."

A signed general consent written in English covers "Release of information, Medical Surgical consent, personal valuables, and directory information/disclosure-non disclosure." The signature of patient #9 appears below a statement that reads in part, " I certify that I have read the foregoing ... " Patient #9 who did not speak or read English could not have read the consent. No documentation reveals how the hospital made the parts of this consent known to patient #9.

Following initial diagnostics, the physician impression was "Possible punctuate right ureter, right-sided hydronephrosis, most likely pyelonephritis with intractable right flank pain." Patient #9 was admitted for IV hydration, antibiotics, and pain management, with a plan to perform a hepatitis panel and ultrasound of the right upper quadrant.

On 11/27/2009 at 4 pm, a nursing progress note states in part "Received PT (patient) from the ED @ 1600 via stretcher. Pt AOx3 (alert and oriented times three)" and "Waiting for pt (patient) boyfriend to come for communication due to pt only speaks Spanish."

The admission database indicates that information for patient #9 was obtained from: "Boyfriend and patient " and reveals "language" as a learning barrier/special need.

On 11/28 at 3:37 pm, a nursing note states in part, " ....Pt. is Spanish speaking. Unable to speak English. Patient knows very few English words. Spouse in room during the day to translate." A physician wrote an order for a Foley catheter. At 5:14 pm, nursing staff writes in part, "Staff from ICU that speaks Spanish came and explained foley catheter to pt and that Dr. ordered."

On 11/29 at 7:13 pm, a nurse writes in part, " ....Spanish speaking pt has husband in room for translation." The nurse continues "Upon return to room, patient sleeping. Bag lunch left for pt and husband informed of new orders. Husband stated he will call when pt wakes for medication to be administered." The significant other of patient #9 was sometimes called a "Boyfriend" and sometimes called a "Husband." In the absence of a translator, patient #1 required the help of her significant other to understand treatments and care. It is not documented if patient #9 wanted her health information mediated by her significant other, nor could staff assess the quality of information being given to patient # 9 by her significant other.

At 8:12 pm, the same nurse writes "Spanish speaking pt is without family to translate at this time. Pt. is able to communicate with nonverbal ques (cues)."

On 11/30 at 11:30 am, a nurse writes in part, "Pt awake and alert. Able to communicate with pt minimally due to language barrier. Pt. states that she has pain over her abd (abdomen) however, unable to rate it and describe it. C/O headache. Medicated for pain." In the absence of a translator, nursing was unable to fully and consistently assess patient #9 for pain.

On 12/1 at 1:42 am, a nurse documented "Awake. A & O x 3 (alert and oriented to three spheres). Limited communication secondary to language barrier." At 8:04 am, an RN documented "Pt. resting in bed. Pt Spanish primary language. Pt denied any pain when asked in Spanish." Documentation does not reveal who translated this information for patient #9. Patient #9 discharged from the hospital on 12/1. Discharging information was given in Spanish text. However, patient #9 discharged having had only one instance of hospital level interpretive services offered to her during admission.

The hospital Diversity orientation for new employees informs them of the"Language Bank" which holds a comprehensive list of translators. In addition, employees learn of a "Professional Interpreter Exchange" with accompanying phone number as another method for obtaining interpreter services, and signing for the deaf.

Interview with one RN revealed she had been working at the hospital approximately one and a half years. The RN revealed that when she has had Spanish-speaking patients, she accesses select employees, in other departments for interpretation, namely "Dietary." The RN did not otherwise know of the online Language Bank, or how to access interpreter services.

A review of the hospital's rights information states that patients:
"Have a right to participate in your plan of care, including;
- the right to received as much information as needed to make informed decisions
- be informed of your health status
- be involved in planning and treatment
- request or refuse any treatment, medication or procedure
- leave the hospital against hospital or physician advice ,
- receive information in a manner tailored to the patient's age, language, and ability to understand.
-be provided with interpreting and translation services, as necessary,
- give or withhold informed consent"

Initially, the hospital did not use a translator to inquire if patient #9 wanted translation of her confidential health information by her significant other, whose actual significance to patient #9 was never established. In the absence of a translator, the hospital could not assess the quality of translation, nor patient #9's understanding of her care. Consequently, patient #9 could not use her basic rights to participate in treatment when the hospital failed to obtain translation services as outlined by regulation and hospital policy.

Based on review of policy and procedure and the patient record, it is revealed that a restraint order for patient #8 was for soft limb medical restraints, though patient #8 was placed in hard rubber restraints as evidenced by:

Patient #8 is a 43-year-old male who entered the emergency department (ED) on 11/24/2009 via police emergency petition after he was found running around the neighborhood, damaging properties while naked. Patient #1 was noted to have increasingly bizarre behaviors, and paranoia.

Patient #8 eloped from the ED, and was brought back by police. Patient #8 became combative during this process and was placed in 4-point hard-rubber restraint on 11/25 at 9:16 am to 11:18 am. Patient #8 received an antipsychotic and an anti-anxiety agent.

The order for 4-point restraint on 11/25/2009 at 9:17 states, Assessment for Medical Restraint, "The patient has been assessed and determined to be unable to cooperate with necessary medical treatments and procedures." The type of restraint indicated was "Soft limb." Instructions to the nurse read "Document initial restraint application and discontinue in 2 HR (hour) safety check."

The initial nursing restraint assessment reveals that patient #8 was placed in "Locked rubber" restraints, not soft limb restraint. Though patient #8 was placed in locked rubber restraint, an order was written for soft limb medical restraints. Medical restraint management differs from behavioral restraint in many ways. Observation, orders, assessment criterion, and time parameters are some of those differences. Therefore, writing a medical restraint for a behavioral patient is not accurate regarding actual care, and carries the risk of a lapse in the rights of behavioral patients.

Based on review of policy and procedure, and patient records, it is revealed that restraints for 2 of 11 patients reviewed were continued after the discontinuation of unsafe conditions as evidenced by:

1. Patient #8 is a 43-year-old male who entered the emergency department (ED) on 11/24/2009 via police emergency petition after he was found running around the neighborhood, damaging properties while naked. Patient #1 was noted to have increasingly bizarre behaviors, and paranoia.

Patient #8 eloped from the ED, and was brought back by police. Patient #8 became combative during this process and was placed in 4-point hard-rubber restraint on 11/25 at 9:16 am to 11:18 am. Patient #1 received an antipsychotic and an anti-anxiety agent.

Fifteen minute checks on the seclusion/restraint flow sheet indicate that at 10 and 10:15 am, patient #8 was quiet and accepting of limits. From 10:30 am through release of 11:18 am, patient #8 was quiet, with his eyes closed. Restraints were continued at least one hour beyond the time in which patient #8 became calm.

2. Patient #11 is 22-year-old female admitted on 12/14/2009 at 5:01 am on involuntary status from another hospital. Patient #11 had diagnoses of bipolar disorder and mental retardation. Patient #11 has a hearing disability, uses hearing aids, and has a speech impediment. A signing interpreter was engaged to help communicate with her. Patient #1 was intolerant of limit setting and the word "No." She began throwing chairs, grabbing staff and pushing staff. Patient #11 was placed in on 1:1 initially and medication was given.

Staff continued to intervene on increasingly aggressive behaviors, but placed patient #11 in 4-point restraint from 7:05 pm until 11:15 pm. A late nursing note of 12/15 at 5:15 pm states that patient #11 would, " ...become settled for 5 minute periods, and them release self from the left upper restraint and then begin to yell out and beat on her legs and the side of the bed" and "She continued with episodes occasionally until 10:40 pm."

Fifteen minute documentation on the restraint/seclusion flow sheet indicates that from 7:15 pm, patient #1 was "quiet" and "unpredictable" for the next hour through 8 pm. Patient #11 is documented to be "quiet" and "friendly" for the next hour through 9 pm, and asleep on all other 15-minute assessments until release at 11:15 pm. Documentation does not support that patient #11 remained a danger to herself or others beyond the initial time of restraint application.

Patients #8 and 11 were restrained appropriate dangerous behaviors. However, staffs did not discontinue restraints at the earliest possible time when they were no longer a danger to themselves or others.