The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on a review of 3 open records and 9 closed records and documentation including the hospital policy titled "Interpreter Services and Other Communication Services" (dated 4/28/2016), during the survey on 10/25/2017, it was determined the hospital failed to follow policy and procedure related to the provision of interpreter services for Patient #7 and did not protect the patient's right to participate in the development and implementation of his or her plan of care.

Further review of the "Interpreter Services and Other Communication Services" policy revealed that "Family members may not act as an interpreter for the patient". Patient #7 is Russian-speaking only. The RN documented in Patient #7's admission data base the "Preferred Language for Receiving Health Care Information" as "Russian" and noted the use of a translation aid, "CYRACOM dual handset phone" under "Interpretation/Translation Aids Used". A physician note stated "[the patient] is Russian and speaks minimal English, but the [child] speaks English well". Additionally, Patient # 7's medical record contained notes that referenced the availability of interpretive services in several instances, however, no evidence was provided supporting that the staff's effort to establish a baseline method of communication through an interpreter. Failure to provide medical information in a language or manner understood by the patient diminished the patient's ability to participate in care and to make informed medical decisions.

Based on a review of 3 open records and 9 closed records, during the survey on 10/25/2017, it was determined the hospital failed to ensure Patient #7's right to make informed decisions regarding his or her care. The hospital failed to establish the capacity of the patient to make independent decisions regarding his or her care or confirm the patient's request to designate a representative to make informed decisions about care. Review of Patient #7's medical record revealed two family members acting as the patient's surrogate decision maker as evidenced by signed consents and documentation by staff as using the family members as interpreters to communicate with the patient. The hierarchy of family surrogacy was not followed prior to going to a designated family representative for decisions regarding care. Patient # 7 was admitted for sepsis and had orders for an emergent procedure that required consent. No evidence was found the hospital documented the patient lacked capacity to make informed decisions or that the patient authorized a family member to act as a surrogate.

Based on review of 3 open medical records and 9 closed medical records, it was determined the hospital failed to present evidence the patient or the patient's representative was provided "An Important Message from Medicare" (IM) notice of rights. Specifically, the hospital did not provide the initial IM for 5 of 12 patient records and did not provide the secondary IM for 3 of 12 patient records reviewed.

Review of medical records for Patient (Pt) # 4, Pt# 5, Pt# 7, Pt# 11 and Pt# 12 revealed no initial IM was provided. Additionally, Pt# 3, Pt# 4 and Pt# 8 records were missing the secondary IM as required.