HospitalInspections.org

Based on review of hospital policy and 8 open and 3 closed medical records, it was determined that the hospital failed to uphold the patient's right to be informed and involved in their care by not providing timely interpreter services for Patient #2 (P2); and the hospital failed to follow their policy for obtaining Patient #3's (P3) or the patient's representative's signature for consent for treatment and the Important Message from Medicare.

1) Per Hospital Policy titled "Patient Care Services" (Dated 06/15), "It is the policy of (this facility) to ensure patients who do not speak English have the ability to effectively communicate with all members of the healthcare team. It is preferable to use trained interpreters with medical knowledge instead of family, personnel, etc. as this can be considered a conflict of interest, breach of confidentiality, and HIPAA violation."

Further review of this policy (page 3), identified the statement "Ask interpreter to question patient to identify those persons who are permitted to participate in conversation. Document in patient's chart that interpretation services were performed, who was present and a summary of the conversation that transpired."

P2 was a 60+ year old non-English proficient patient who spoke an Indian dialect and presented to the Emergency Department (ED) for shortness of breath. Documentation indicated that P2 was alert and oriented. The nursing assessment revealed documentation of the preferred language for the patient, however it was noted that" interpreter services were not requested" and that 'the family member' was present and would translate. Review of the record failed to identify documentation of a call to an interpreter to establish a baseline for the patient and determine what his/her preference for communication would be. Also consent for treatment was signed by P2's adult child.

A general admission note written by a physician from later that evening stated "Patient is a difficult historian secondary to language barrier, however P2's family member assists with the history". No documentation was found stating that certified interpreter services were called at this time.

Documentation by the physician on the admission H&P the following day revealed a note that stated "Blood Pressure (BP) medication was given (by staff), however while finally speaking to the language line it was found that patient took their own BP medication from home earlier today. Medication is now locked up and BP will be monitored closely".

Review of a copy of the discharge instructions for P2 revealed that all the information provided, including medication instructions, were printed out in English.

2) Review of hospital policy "Informed Consent" (revised 10/18), it was stated "The licensed and/or Certified Healthcare Provider's role includes: Asking the patient if they have any questions, obtaining the patient's signature."
P3 was a 90+ year old who was living independently and presented to the Emergency Department (ED) after a fall. Nursing and physician notes from the ED state that the patient was alert and oriented to person, place and time, however the consent form for treatment stated "patient unable to sign". No documentation could be found to explain why the patient was not able to sign the informed consent.

Review of hospital policy "Medicare Important Message", (dated 8/15), stated "If the patient is incompetent or incapable of receiving the notice, and the Registrar cannot obtain the signature of the patient's representative through direct personal contact, the Registrar must telephone the representative to advise him/her of the patient's rights, including the right to appeal the discharge". It further states that documentation of this contact and/or attempts thereof must be in the notes.
Review of the Important Message for P3 revealed "Patient unable to sign" with no documentation as to why the patient was unable to sign. No documentation was found to determine if the patient's adult child was provided the Important Message. Consent was obtained from the patient 3 days after the patient's admission when surveyors were on site and brought the situation to the attention of staff.

In summary the facility failed to follow their policies for properly obtaining informed consent and for failure to provide documentation that P3 or their representative were properly informed of the Important Message within 48 hours of admission. The hospital also failed to use interpreter services per their policy to ensure accurate historical information was obtained from P2, determine his/her preferences and consent for care, acquire medication information, and determine his/her understanding of the discharge instructions.

Based on a review of the hospital special police job description, training and duties, it was determined that Special Police (SP) may independently decide to arrest and seek community police interventions involving patients without clinical/administrative oversight; and Special Police may decide to use force on patients without Clinical/Administrative oversight.

Review of a Job Summary for employed Special Police (SP) who have arrest capabilities through the local police department revealed in part, "2. Responds to calls for service on the hospital campus, evaluates the situation and determines appropriate course of action. Liaisons with local law enforcement when necessary."

Review of the hospital "Police Officer's Introduction to Law Program" Part 5 Maryland Laws (Applicable to Hospital Property) stated in part, "Use of force: A police officer may use reasonable force to overcome resistance to a lawful arrest ..."

While there was no evidence that patients had been harmed, these hospital descriptors of the SP scope of officer-to-patient interactions indicated a lack of a clinical determination as to who was a patient, and a lack of clinical oversight and decision-making for those determined to be patients. Therefore, patients for whom the SP was authorized to "determine a course of action" and use "reasonable force to overcome resistance to a lawful arrest ..." did not receive care in a safe setting.