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Based on the review of patient records and interviews with staff it was determined that the hospital failed protect the rights of patient #1 as evident by the failure to obtain needed translator services for this Hispanic male as cited at A 131 and based on the failure to obtain needed medical services in a timely manner as noted at A144.

Based on a review of 11 medical records, hospital policy, and other documentation, it was determined that one patient (patient #1) was not able to take part in decisions about his own treatment because his need for a translator was not identified in the nursing care plan and he did not receive translator assistance for his admitting treatment consent, nor did the nursing staff access translation services to complete his admission nursing assessment.


A review of the the hospital policy for "Accessing services for patients with special communication needs including interpreters" (revised 1/2008) revealed in part... "3. At the time of registration in the Emergency Department, or at the time of admission, the nursing staff evaluates the patient's clinical condition as well as any special barriers to effective communication. If a barrier to effective communication is noted, the nurse documents the special need on the patient's Planning Record or Emergency Services Record and notifies the communications department and Patient Advocacy of the need for assistive methods of communication."


Patient #1 was Hispanic male who presented to the emergency department (ED) with abdominal pain. Patient #1 was diagnosed with acute pancreatitis, and hypertension. He was admitted on 12/26/2012 at 2328 to the hospital but was boarded in the emergency department (ED) until 1530 on 12/28/2013 due to a bed shortage on the critical care unit.


Patient #1 was alternately assessed by nursing as speaking "Some English" and "Spanish speaking only." A history and physical revealed the physician statement of "38 yo Spanish speaking male presents with acute abdominal pain ... " ED documentation reveals that patient #1's daughter interpreted for him at some point during the first day. Patient #1's initial consent for treatment was printed in English and signed by him on 12/26/2012 at 2330 without any evidence of the provision of interpreter services.


Documentation revealed that patient #1 signed a Spanish printed consent for radiology, and with the help of an interpreter on 12/28, was offered a central line consent (which he refused). However, no record documentation reveals interpreter assistance during his first admission day in the ED. Although patient #1 was "admitted" to the ED, documentation of 12/28/2012 at 1550 reveals there was no admission assessment due to a "language barrier." Additionally, there was no nursing care plan entry to indicate a need for interpreter services, and no documentation could be found of any education on his diagnosis or plan of care. According to the medical record, the patient's plan of care was not discussed with him through an interpreter until 1.5 hours prior to his death.

Other documentation revealed that on 12/27, patient #1 received translation services alternately for "15 minutes abdominal pain, vomiting," and "20 minutes - Pt is having abdominal pain and cannot pass urine." On 12/28/12, other documentation reveals translation services for patient #1, documented as "Pt will be admitted to Critical Care, he has pancreatitis and a distended abdomen. Interpreted for RN throughout the morning. Total time 45 minutes."

In summary, evidence indicated that patient #1 received inconsistent and incomplete interpreter services as evidenced by no nursing care plan for interpreter services, and no initial nursing assessment. The hospital allowed patient #1's daughter to interpret at some time during the first hospital day, which does not meet the standard of care. Therefore, the hospital failed to allow patient #1 to participate in his care planning and provision by failing to provide interpreter services.

Based on record review of 11 patients, it was determined that the hospital 1)failed to place patient #1 in the best setting for safe and effective care and failed to render definitive treatment while patient #1 boarded in the emergency department (ED).

Patient #1 spent 40 hours in the ED after arriving with nausea, vomiting, shortness of breath, and abdominal distention. An abdominal CT (computed tomography) scan was performed approximately three hours after arrival, which showed free fluid in the abdomen, ascites (a large collection of fluid in the abdomen), and dependant atelectasis (a collection of fluid in both lung bases indicating he was not adequately expanding his lungs).

Patient #1 received IV fluids and had blood work done. His blood work showed metabolic acidosis and an electrolyte derangement. His electrolytes were repleted with IV infusions. Acute metabolic acidosis is a condition in which the body has too much acid to function well. It often occurs with shock, renal or other organ failure, and/or prolonged low oxygen states. Most symptoms are caused by the underlying disease or condition that is causing the metabolic acidosis. Metabolic acidosis is a dire condition and usually causes hyperventilation as the body tries to rid itself of excess acid, and can cause confusion and lethargy. Severe metabolic acidosis can lead to shock or death. Patient #1's respiratory rate was sustained in the 30-38 breathes per minute range for hours prior to his death.

Ascites is a condition in which there is a build-up of fluid in the abdominal cavity. It is usually caused by organ malfunction; in this case, the patient had an acute inflammation of his pancreas. The fluid build-up causes pressure on all of the organs in the abdomen and makes lung expansion and breathing difficult. There is no evidence in the medical record that the staff measured patient #1's abdominal girth, or otherwise objectively measured how big his abdomen was getting. A nurse's note from 12/28/12 at 0439 notes that the patient's abdomen was visibly larger, yet still no documentation indicated that anyone measured his abdominal girth.

In addition, although he was short of breath and on supplemental oxygen, no blood gases were obtained to determine how efficient his breathing was, or whether he was compensating for the metabolic acidosis by hyperventilating. Even though the abdominal CT done soon after arrival showed that patient #1's lungs were not expanding completely, there is no evidence of a chest x-ray or any other follow-up on the medical record.

Patient #1 also had very low urine output while he was in the ED. At the same time he was receiving IV fluids at a high rate (200ml /hr), he was urinating only about 100 ml a shift. He had an indwelling urinary catheter inserted during hour 36 in the ED but maintained a very low output. The low urine output may have been another sign of organ malfunction and another indication of the patient's deteriorating condition, but no documentation was found indicating any follow-up or treatment of this dire symptom.

Because patient #1 spent 40 hours in the ED, he received inadequate diagnostics and no definitive treatment for the conditions causing his symptoms. Even though patient #1 was followed by the intensivist in the ED, he was not treated like an ICU patient. The lack of adequate diagnostics, effective monitoring, and definitive treatment meant that by the time patient #1 got to the CCU (critical care unit), his blood pressure was high (157/95), his heart rate was high (130), and his respirations were shallow and fast (38). He experienced a period of agitation that may have been due to a lack of adequate oxygenation complicated by the metabolic acidosis. His body could no longer compensate and he suffered a cardiopulmonary arrest within a few hours of arriving in the CCU.

Based on interviews, and review of documentation, policies, and the hospital's employee crisis prevention training for hospital security it was determined that one security guard (SG1) involved in restraining patient #1 had not received any training on evidence-based physical holds, and two security guards, (SG2, and SG3) had no current recertifications in their training.
Patient #1 was a Hispanic male who presented to the emergency department (ED) with abdominal pain. Patient #1 was diagnosed with acute pancreatitis, and hypertension. He was admitted on 12/26/2012 at 2328 to the hospital but was treated in the emergency department by intensivists until 1530 of 12/28/2013 due to a bed shortage on the critical care unit (CCU).

On 12/28/12 at 1530, patient #1 was transferred to the CCU. During admission patient #1 had shown no evidence of aggression. However, at approximately 1700, patient #1 began to show aggressive behaviors. Patient #1 got out of bed, pulled out his IV's and Foley, punched a physician, and picked up the IV pole, flailing it at staff.

According to documentation, a nurse closed the glass door keeping patient #1 in his room where he continued to flail the IV pole until security staff arrived and entered the room. Two security of four, responding security guards SG1 and SG2, were able to get the pole away from patient #1, and patient #1 fell to the floor. There, he was restrained on his side until he received ativan 4 mg intramuscularly administered by a RN.

Review of security training for hold techniques reveals that the hospital trains security in an evidence-based method, with an initial orientation and annual updates. Investigation revealed SG1 had training for mechanical restraint, he had no training for manual holds. Review of training for SG2 reveals no recertification of manual hold techniques since 12/9/2011, more than one year prior to the incident, and SG3 had no recertification since 9/30/2005.

The hospital failed to provide training for manual holds to one security staff prior to performing manual restraint, and failed to keep other security staff up-to-date on training.

Patient #1 was Hispanic male who presented to the emergency department (ED) with abdominal pain. Patient #1 was diagnosed with acute pancreatitis, and hypertension. He was admitted on 12/26/2012 at 2328 to the hospital but was treated in the emergency department by intensivists until 1530 of 12/28/2013 due to a bed shortage on the critical care unit (CCU).

On 12/28/12 at 1530, patient #1 was transferred to the CCU. During admission patient #1 had shown no evidence of aggression. However, at approximately 5 pm, patient #1 began to show aggressive behaviors. Patient #1 got out of bed, pulled out his IV and Foley, punched a physician, and picked up the IV pole, flailing it at staff.

A nurse closed the glass door keeping patient #1 in his room where he continued to flail the IV pole until security staff arrived and entered the room. Two security were able to get the pole away from patient #1, but patient #1 fell to the floor. There, he was restrained on his side on the until he received ativan 4 mg IM. Review of the order for ativan reveals no dosage or route.

The Pharmacy explained that under emergent code situations, the RN is able to pull the medication from the Pyxis machine based on a verbal order and a manual override of the usual Pyxis lockouts. The RN is then to place a verbal order for the medication to the Pyxis linked order so that it can be signed off by the physician. However, the record reveals a Pyxis link without the elements of the verbal order, and therefore, no dose or route. The hospital states that while a verbal order was made, it was not documented as ordered. The hospital failed to document a verbal order within the standard of practice.