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JACKSON PARK HOSPITAL 7531 S STONY ISLAND AVE CHICAGO, IL 60649 Sept. 1, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



A. Based on document review and interview, it was determined for 1 of 1 (Pt #1) clinical record reviewed of a Spanish speaking patient, the Hospital failed to ensure the patient's right to communication with her health care providers was protected. This potentially affects all Spanish speaking patient.

Findings include:

1. Hospital policy entitled, "Patient Rights," (Review December 2009) reviewed on 8/31/16 at approximately 9:00 AM required, "It is your right as a Patient of Jackson Park Hospital...To expect that we will communicate with you in a language and manner that you understand..."

2. Hospital policy entitled, "Language Assistance," (Review date November 2015) reviewed on 8/31/16 at approximately 9:15 AM required, "I. Purpose: To ensure access to healthcare information and services for limited-English speaking and/or non English speaking patients...II. Policy: It is the policy of Jackson Park Hospital to provide the same quality service to all patients. By providing language assistance to patients with a language...barriers...III. A. The nurse on the patient care unit...If it is apparent that the individual needs or...a language interpreter...

3. The clinical record of Pt #1 was reviewed on 8/31/16 at approximately 10:15 AM. Pt #1 was an [AGE] year old female admitted from the emergency department on 9/8/15 with a diagnosis of acute psychosis. Pt #1's emergency department (ED) record dated 9/8/15 included Pt #1's preferred language as Spanish. Pt #1's clinical record lacked documentation of a Spanish speaking interpreter being provided when needed: Emergency Department documentation dated 9/8/15 included, "Preferred Language: Spanish..."; Physician documentation dated 9/9/15 at 1:51 AM included, "...Communication barrier...Unable to obtain history from patient as she is speaking unknown language"; Nursing documentation dated 9/10/15 at 7:42 PM indicated, "Unable to assess due to language barrier"; Nursing documentation dated 9/11/15 at 6:33 AM indicated, "Pt is Spanish speaking"; and Nursing documentation dated 9/17/15 at 8:18 AM indicated, "Patient is primarily Spanish speaking."

4. On 8/31/16 at approximately 12:30 PM the RN (E #1) caring for Pt #1 on 9/13/15 was interviewed. E #1 stated, " I remember the patient. She did not speak English and at times would scream. She was alert and orient by agitated. People just could not communicate with her. No one else on the unit speaks Spanish just me and maybe a few house keepers."

5. The Senior Vice President of Nursing stated during an interview on 9/1/16 at approximately 9:35 AM that, "We don't use lay people as interpreters and if an interpreter is used that should be documented in the clinical record. I would expect the language line to be used if needed."

6. The Hospital presented an attestation letter dated 9/1/16 that included, " This is in reference to (Pt #1), admitted s August 5, 2015 and September 8, 2015. In reviewing our logs we have determined that no call was placed to an outside vender for interpreting services. "


B. Based on document review and interview, it was determined for 1 of 1 (Pt #1) clinical record reviewed of a Spanish speaking patient, the Hospital failed to ensure the patient's right to have her family informed of her medical condition was protected. This potentially affects all Spanish speaking patient.


Findings include:

1. Hospital policy entitled, "Patient Rights," (review date December 2009) reviewed on 8/31/16 at approximately 9:00 AM required, "Policy...Privacy and Confidentiality: To be informed of the nature of his/her illness...This information should be communicated in terms the patient can reasonably be expected to understand. When it is not medically advisable, or physically possible, to give such information to the patient, the information should be made available to a legally authorized individual."

2. The clinical record of Pt #1 was reviewed on 8/31/16 at approximately 10:15 AM. Pt #1 was admitted on [DATE] was from the emergency department (ED) with complaints of violent behavior. Pt #1's ED record included Pt #1's preferred language as Spanish and lists the daughter as the contact person to be notified. Pt #1 found on the bathroom floor on 8/6/15 at 11:00 AM with complaints of right leg pain. Pt #1 was evaluated by the physician and x rays were ordered. Pt #1's right hip x ray indicated, "Displaced and angular para-prosthetic femoral fracture." Pt #1's clinical record lacked documentation of the daughter being notified of the incident.

Pt #1 was admitted again to the ED on 9/8/15 with complaints of bizarre paranoid behavior. Pt #1's record included Pt #1's preferred language as Spanish and lists the daughter as the contact person to be notified. Documentation included in an incident report dated 9/8/15 at 8:40 PM that Pt #1 fell from the ED cart. Nursing documentation dated 9/8/15 included, "...Abrasion to the forehead noted...order received for CT of head." The clinical record lacked documentation that Pt #1's daughter was notified of the incident.

3. The Senior Vice President of Nursing Services stated during an interview on 9/1/16 at approximately 9:35 AM that, "If there was a patient incident I would expect the family to be notified. "