HospitalInspections.org

Based on interviews, policy and procedure review, and record review of 5 patients, it was determined that in 4 of 5 patients, Patients (1, 2, 3, and 4) the registered nurse failed to supervise and evaluate the nursing care of each patient.

The hospital had a system-wide, Interpretive Services Policy titled "Communication with Persons with Limited English Proficiency (LEP)", Effective Date of 08/01/2011. This policy states under "Requirements: 1. Identifying LEP Persons and their Language. PeaceHealth health care entities promptly identify the language and communication needs of the LEP person.....In addition, when records are kept of past interactions with patients (clients and residents) or family members, the language use to communicate with the LEP person is included as part of the record."

On 03/27/2012 at 1416, Interviewees A and D met with the surveyor to discuss the hospital's Interpreter Services and accessing those services. The services include a wide catalog of languages available either face to face, by phone, or translation of a document. In 2011, it was identified that system-wide, there was a lack of consistency in utilizing and documenting the use of Interpreter Services. The "Peace Health Special Accommodations Data Collection Form - PHOR" was developed on 09/22/2011, to address these concerns.

Recently it was identified by Interviewees A and D that the forms generated by the Emergency Department were incomplete. On 03/09/2012 from 1000 to 1100, Interviewees A & D met with the Emergency Department Nurse Manager and formed a solution that included developing a series of colored, laminated cards each identifying a specific language and describing access to Interpreter Services. The laminated cards were in the process of development but not yet implemented at the time of the complaint investigation survey.

From patient lists of non-English or limited English speaking patients cared for at the facility from 02/01/2012 through 02/29/2012, five clinical records were selected for review. The clinical record reviews occurred with either Interviewee A or Interviewee C accessing the computerized record and this was combined with a review of printouts of specific pages from the electronic records dealing with nursing care activities and review of encounter logs maintained by Interpreter Services.

The "Peace Health Special Accommodations Data Collection Form - PHOR" included an area on the form below the large area devoted to the patient and support person assessment. This rectangular area stated: "Unable to Assess Patient for Special Accommodations due to:" Below that was a rectangular box containing a line for "Staff Signature," "EMR#," "Date," and "Time." Below that was a rectangular box containing the following:

"(Checkmark symbol) If any answers to the above questions are yes, continue filling out the remainder of the form and offer the Special Accommodations Brochure.

Limited English Proficiency identified (including sign language)

Interpreter contacted: (Checkbox) Yes Date/Time: ____________ Language: ___________

For Clinical Staff use Only ___________________________________________________________
Signature Initials EMR# Date Time"

When reviewed at approximately 1430 on 03/27/2012, 4 of 5 patient records (Records # 1, 2, 3, and 4) contained incomplete "Peace Health Special Accommodations Data Collection Form - PHOR" forms.

Patient # 1: This patent received a cardiac procedure at the hospital on 02/02/2012. The staff member filling out the form wrote that both the patient and the support person spoke Korean at home. Additionally, the staff member wrote that both the patient and the support person spoke English "Well."

The "Peace Health Special Accommodations Data Collection Form - PHOR" states: "(Checkmark symbol) if the patient or the support person answers with a language other than English on the above question, and anything other than 'very well' on the below question, they shall be designated as LEP (Limited English Proficient)"

There was nothing written in the "Unable to Assess Patient for Special Accommodations due to:" rectangle. There was nothing written in the "Limited English Proficiency Identified" rectangle.

Patient Record # 2- This patient received a cardiac procedure at the hospital on 02/02/2012. The staff member that filled out the form wrote that the patient spoke Laos at home and did not indicate which language the support person spoke at home. Additionally, the staff member wrote that both the patient and the support person spoke English "Not Well." There was nothing written in the "Unable to Assess Patient for Special Accommodations due to:" rectangle. There was nothing written in the "Limited English Proficiency Identified" rectangle.

Patient Record # 3- This patient received obstetrical services at the hospital on 02/13/2012. The staff member that filled out the form wrote that the patient spoke and the support person spoke "French/Bambara" at home. The staff member wrote that the support person spoke English "Well" but the patient spoke English "Not at all." There was nothing written in the "Unable to Assess Patient for Special Accommodations due to:" rectangle. There was nothing written in the "Limited English Proficiency Identified" rectangle.

Patient Record # 4- This patient received a inpatient services at the hospital from 02/17/2012 to 02/23/2012. The staff member that filled out the form wrote that the patient spoke Spanish at home and did not indicate which language the support person spoke at home. Additionally, the staff member wrote that both the patient spoke English "Not well" and the support person spoke English "Well." There was nothing written in the "Unable to Assess Patient for Special Accommodations due to:" rectangle. There was nothing written in the "Limited English Proficiency Identified" rectangle.

These findings were shared with Interviewee A, the stated developer of the "Peace Health Special Accommodations Data Collection Form - PHOR" form at approximately 1500 on 03/27/2012. The findings reflect the situation that brought about the 03/09/2012 meeting with the Emergency Department Nurse Manager. However, the findings pointed to a wider problem in the use of this form as the forms listed above included staff from the Cardiac Procedure Room, Obstetrics, and an inpatient Neurology unit.

In response to these findings Interviewee A provided the 03/27/2012 E-mail from Interviewee A to Nurse Managers clarifying that the "Peace Health Special Accommodations Data Collection Form - PHOR" must be consistently and completely filled out. Also, that the form be filed in the patient's record whether interpreter services are offered and declined or offered and utilized.

Based on interviews, policy and procedure review, and record review of 5 patients, it was determined that in 4 of 5 patients, Patients (1, 2, 3, and 4) the registered nurse failed to supervise and evaluate the nursing care of each patient.

The hospital had a system-wide, Interpretive Services Policy titled "Communication with Persons with Limited English Proficiency (LEP)", Effective Date of 08/01/2011. This policy states under "Requirements: 1. Identifying LEP Persons and their Language. PeaceHealth health care entities promptly identify the language and communication needs of the LEP person.....In addition, when records are kept of past interactions with patients (clients and residents) or family members, the language use to communicate with the LEP person is included as part of the record."

On 03/27/2012 at 1416, Interviewees A and D met with the surveyor to discuss the hospital's Interpreter Services and accessing those services. The services include a wide catalog of languages available either face to face, by phone, or translation of a document. In 2011, it was identified that system-wide, there was a lack of consistency in utilizing and documenting the use of Interpreter Services. The "Peace Health Special Accommodations Data Collection Form - PHOR" was developed on 09/22/2011, to address these concerns.

Recently it was identified by Interviewees A and D that the forms generated by the Emergency Department were incomplete. On 03/09/2012 from 1000 to 1100, Interviewees A & D met with the Emergency Department Nurse Manager and formed a solution that included developing a series of colored, laminated cards each identifying a specific language and describing access to Interpreter Services. The laminated cards were in the process of development but not yet implemented at the time of the complaint investigation survey.

From patient lists of non-English or limited English speaking patients cared for at the facility from 02/01/2012 through 02/29/2012, five clinical records were selected for review. The clinical record reviews occurred with either Interviewee A or Interviewee C accessing the computerized record and this was combined with a review of printouts of specific pages from the electronic records dealing with nursing care activities and review of encounter logs maintained by Interpreter Services.

The "Peace Health Special Accommodations Data Collection Form - PHOR" included an area on the form below the large area devoted to the patient and support person assessment. This rectangular area stated: "Unable to Assess Patient for Special Accommodations due to:" Below that was a rectangular box containing a line for "Staff Signature," "EMR#," "Date," and "Time." Below that was a rectangular box containing the following:

"(Checkmark symbol) If any answers to the above questions are yes, continue filling out the remainder of the form and offer the Special Accommodations Brochure.

Limited English Proficiency identified (including sign language)

Interpreter contacted: (Checkbox) Yes Date/Time: ____________ Language: ___________

For Clinical Staff use Only ___________________________________________________________
Signature Initials EMR# Date Time"

When reviewed at approximately 1430 on 03/27/2012, 4 of 5 patient records (Records # 1, 2, 3, and 4) contained incomplete "Peace Health Special Accommodations Data Collection Form - PHOR" forms.

Patient # 1: This patent received a cardiac procedure at the hospital on 02/02/2012. The staff member filling out the form wrote that both the patient and the support person spoke Korean at home. Additionally, the staff member wrote that both the patient and the support person spoke English "Well."

The "Peace Health Special Accommodations Data Collection Form - PHOR" states: "(Checkmark symbol) if the patient or the support person answers with a language other than English on the above question, and anything other than 'very well' on the below question, they shall be designated as LEP (Limited English Proficient)"

There was nothing written in the "Unable to Assess Patient for Special Accommodations due to:" rectangle. There was nothing written in the "Limited English Proficiency Identified" rectangle.

Patient Record # 2- This patient received a cardiac procedure at the hospital on 02/02/2012. The staff member that filled out the form wrote that the patient spoke Laos at home and did not indicate which language the support person spoke at home. Additionally, the staff member wrote that both the patient and the support person spoke English "Not Well." There was nothing written in the "Unable to Assess Patient for Special Accommodations due to:" rectangle. There was nothing written in the "Limited English Proficiency Identified" rectangle.

Patient Record # 3- This patient received obstetrical services at the hospital on 02/13/2012. The staff member that filled out the form wrote that the patient spoke and the support person spoke "French/Bambara" at home. The staff member wrote that the support person spoke English "Well" but the patient spoke English "Not at all." There was nothing written in the "Unable to Assess Patient for Special Accommodations due to:" rectangle. There was nothing written in the "Limited English Proficiency Identified" rectangle.

Patient Record # 4- This patient received a inpatient services at the hospital from 02/17/2012 to 02/23/2012. The staff member that filled out the form wrote that the patient spoke Spanish at home and did not indicate which language the support person spoke at home. Additionally, the staff member wrote that both the patient spoke English "Not well" and the support person spoke English "Well." There was nothing written in the "Unable to Assess Patient for Special Accommodations due to:" rectangle. There was nothing written in the "Limited English Proficiency Identified" rectangle.

These findings were shared with Interviewee A, the stated developer of the "Peace Health Special Accommodations Data Collection Form - PHOR" form at approximately 1500 on 03/27/2012. The findings reflect the situation that brought about the 03/09/2012 meeting with the Emergency Department Nurse Manager. However, the findings pointed to a wider problem in the use of this form as the forms listed above included staff from the Cardiac Procedure Room, Obstetrics, and an inpatient Neurology unit.

In response to these findings Interviewee A provided the 03/27/2012 E-mail from Interviewee A to Nurse Managers clarifying that the "Peace Health Special Accommodations Data Collection Form - PHOR" must be consistently and completely filled out. Also, that the form be filed in the patient's record whether interpreter services are offered and declined or offered and utilized.