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 an onsite survey including review of the "Communication and Interpreter Services (CIS)" policy and 11 patient records, it is revealed that patient #2 was unable to participate in much of her care due to a language barrier for which the hospital failed to obtain interpreter services.

The CIS states in part, " All staff interacting with patients will be responsible for identifying communication needs, language preferences and the need for interpreter services ... " and, " All patients needing interpreter services will be informed of the availability of interpreters provided by (the hospital), and that the services are provided at no cost to the patient, " and Under no circumstances will patients be asked to bring their own interpreters/use family members to interpret ... "

Patient #2 is an elder Haitian female admitted in late March 2014. The hospital noted that patient #2 speaks French Creole, and an interpreter was obtained during her emergency department (ED) stay.

Documentation from the ED reveals "Admission done by phone line interpreter - Arrangement for daughter to come in tomorrow to translate," and " Her gait is unsteady for unknown reasons. She was cooperative with the language line. She appeared tired. Her daughter is scheduled to come in tomorrow to do a more indepth admission assessment."

A Medication Education form shows a handwritten note stating "unable to sign on admit - does not speak English." There was no documentation that interpreter services were obtained to give patient #2 education regarding her medications.

Documentation reveals daily group therapy from which patient #2 was largely absent and noted to be in her room. On the first day of admission, a note states "Pt does not speak much (language barrier)". On the second day of admission, a note states "Patient did not attend group despite prompting." Another group note states "Patient was fully engaged in movement, but verbal communication was a challenge as she speaks Creole/some other type of Creole/Spanish combination." A note on the third day of admission states "Patient able to carry on conversation while talking with PA and nurse." On day 4, the goal was documented as "Patient will verbalize feelings of safety." It is unknown how staff would know if that goal was met unless an interpreter service was being used. Further documentation reveals behaviors of "Withdrawn to room, language barrier."

While there appears to have been a PA and a nurse who were able to communicate with patient #2 on one day, and the universal appeal of dance engaged patient #2 on another group day, no evidence is found that the hospital obtained interpreter services during patient #2 ' s inpatient stay. Additionally, the hospital utilized the patient's daughter for interpreting purposes which does not meet the standard of practice. Therefore, the hospital failed to promote patient #2's participation in her treatment by failing to gain interpreter services so she could do so.
Based on an onsite survey inclusive of a tour of the behavioral health unit, it is revealed that no patient rooms had curtains on the windows, where all other hospital patient rooms had some form of window blind or curtain to provide privacy.

Tour of the second floor behavioral health unit revealed 12 rooms with 24 beds. The patient bedrooms have no standard order for what is assigned as a male or a female designated room. Each room may be assigned as a male or female room as census demands. Inspection of room 2117 revealed two approximate 6 foot high by 4 foot wide windows which look out over the entrance to the hospital and part of the hospital parking lot. Neither window had any type of window covering to provide privacy from persons outside who would be able to see into the room during times when the lights would be on.

Interview with staff reveals that patients change clothing within their individual shower areas. Interview with a patient assigned to room 2117 confirmed that she changes her clothing in the shower area. However, even if not changing clothing, patients still do not have the privacy which window coverings provide, and which are noted on all other patient rooms in the hospital.

Likewise, and based on the fact that it is a behavioral health unit, it is quite possible that some patients would not have the state of mind to know that they should change in the shower area, or conversely, might exploit that there are no coverings on the windows. Further, room 2117 is situated to one side of an architectural corner of the building, so that it is easy for patients of whatever gender assigned to each side of that corner, and even a room further down the hall, to look into windows situated on the other side of the corner. As stated, and depending on room assignment, that could mean males looking into female rooms, or females looking into make rooms.

Staff were unable to state when the curtains were taken down, indicating that the curtains had been down for some time. Staff offered that the curtains were probably taken down for safety reasons. However, it was apparent that the hospital failed to look into safer forms of curtains which could still provide for privacy.

Tour of the rest of the unit revealed patient rooms which looked out over various areas of the hospital grounds, none of which had any type of window covering. Therefore, the hospital failed to provide for patient privacy when it failed to provide for window coverings.

Based on a review of 10 patient records, it is determined that patient #2's discharge plan failed to include follow-up for pregnancy testing post-discharge.

Patient #1 is over-eighteen but under [AGE] year old female with borderline intellectual functioning who is a high school senior living in transitional housing. Patient #1 is listed as an adult voluntary patient, and signed her own consents, but has a guardian. Patient #1 also maintains contact with her mother who is listed as her emergency contact. She is also followed by Child Protective Services.

During patient #1's admission, she reportedly asked a male patient for sex, and was able to avoid staff monitoring for 11 minutes to that purpose. Patient #1 was sent to the emergency department for testing inclusive of a urine pregnancy and STD (sexually transmitted disease) panel, the results of which were not found in the record. Patient #1 refused any further gynecological examination.

The hospital obtained a urine pregnancy and an STD panel immediately following the incident. However, it is not expected that accurate results could be identified so soon after sexual contact. Therefore, patient #1 should have had instruction for gynecologic, possible pregnancy and STD follow-up in her discharge plan. None is found. Despite the fact that a hospital social worker informed the assigned CPS worker of the incident one day following discharge, the hospital failed to evaluate for and share the need of follow-up with patient #1, and/or her guardian.