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11890 HEALING WAY

SILVER SPRING, MD 20904

PATIENT RIGHTS: INFORMED CONSENT

Tag No.: A0131

Based on review of hospital policies and 5 open and 6 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 interpreter services for provider assessments for one of 11 patients (patient #1).
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Per hospital policy titled "Communications and Interpreter Services Policy" (Revised 8/21/18), under "Meaningful Access to Communication/Interpreter services: All staff interacting with patients will be responsible for identifying communication needs, language preferences and the need for interpreter services...Interpretation will be available at all key points of contact 24 hours a day ..."

Patient #1 was a 30+ year old Spanish speaking patient who presented to the hospital for swelling of lower legs. Patient #1 was admitted to a medical unit for management of liver cirrhosis among other medical conditions. From the chart review, it was identified there were three instances were two different providers, a physician assistant and a physician, did not indicate whether an interpreter was used. Two of the documents were progress notes from the second and third day of patient #1's admission as well as a Gastroenterology consult. The hospital could not find evidence that an interpreter was used for those three interactions.

In summary, the hospital failed to obtain interpretive services for multiple interactions involving patient #4's care and treatment and therefore failed to uphold the patient's right to make informed decisions regarding his or her care.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0206

Based on an interview with the hospital's Security Director, it was determined the hospital failed to mandate cardiopulmonary resuscitation certification for all employees who apply restraints.

Interview with the hospital Security Director on 1/29/2019 at approximately 10 am revealed that the hospital does not require security staff who apply restraints to have cardiopulmonary resuscitation (CPR) training.