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 review of policies and procedures, reviews of 15 medical records, and staff interviews it was determined that staff failed to document the provision of interpreter services for each encounter with a patient who had limited English proficiency.

Patient #12 was documented on the initial patient assessment as being Limited English Proficient (LEP) and requiring the use of interpreter services. Review of the patient's medical record and an interview with Staff A on 3/22/16 revealed that staff nurses in the Intensive Care Unit (ICU) document the use of interpreter services being used for education once each shift but not for each encounter with the patient for interactions such as assessments.

The policy "Interpretation/Translation for Non-English Speaking Patient" (policy #2.24 under Patient Rights and Organizational Ethics) outlines the physical procedure for initiating the interpreter service "Cyracom." Cyracom is the use of the telephone interpreter service. This policy fails to instruct the staff as to when they are required to use the interpreter services offered by the hospital and what the staff must document in the patient's medical record to support the use of the interpreter service.

Failure of staff to utilize and/or offer interpreter services for each patient interaction, including each of the patient's physical and neurologic assessments, places the hospital at risk for violating the patient's rights. All identified LEP patients should be provided the ability to receive and give information in a manner that he/she may understand to assure that the patient, or the patient's representative, can effectively exercise his/her right to make an informed decision.
Based on observations in the Emergency Department (ED) and interviews with the ED Nurse Manager on 3/22/16 it was determined that the staff failed to maintain an accurate log of the use and cleaning of the Decontamination Room and failed to clean the decontamination room after the previous use.

Decontamination rooms are used to receive and treat patients, visitors, and employees who have been exposed to hazardous materials while minimizing exposure to staff, other patients, and visitors. Logs should record the hazardous material that had caused the contamination, the date of use, and that the room had been appropriately cleaned by hospital staff. The cleaning process may vary depending on the contaminant.

Observation of the ED on 3/22/16 at 10:15 AM revealed that the decontamination room had been used, was visibly dirty with used towels and dirt on the floor. The ED Nurse manager confirmed this finding and had asked the current ED Charge Nurse if the "decon room" had been recently used. The Nurse Manager stated s/he was not aware of a recent use of the "decon room." The log of the Decontamination Room's use was reviewed. The most recent report contained in the log was dated 1/31/16 at 1643 and listed "facilities" had been notified that the Decontamination Room shower will be used and that the agent was identified as being antifreeze. An interview of the ED Nurse Manager revealed that the Environmental Services Department (EVS) does not keep a log of the cleaning of the Decontamination Room. The ED Nurse Manager contacted EVS to determine if EVS had been made aware of the Decon Room's use and to have the Decon Room cleaned.

A review of the 'EVS Duty List' for the ED revealed that at 0715 each day EVS is to "check the Decontamination Bathroom/shower." According to the Safety Committee meeting minutes for December 2015 the topic of a decontamination shower in the ED log had been discussed and it was identified that no log or documentation had been kept. The recommendation was to complete a log of the decon shower use, it had been implemented, and then no follow-up to that log was indicated in the meeting minutes.

Failure to have the Decontamination Room readily available and clean for potential contaminated victims has the potential to negatively impact the safety and well being of patients, visitors, and staff.

Based on review of 15 medical records it was determined that the hospital failed to document appropriate medical information on the discharge instructions for a patient to include referrals for outpatient services and the patient's medication reconciliation as stated in the providers discharge summary.

Patient #10 was emergency petitioned to the Emergency Department (ED) on 3/14/16 with homicidal ideation (HI). According to the psychiatrist's comprehensive behavioral health assessment the patient had been cleared medically by the ED physician and was to be transferred to another hospital when an adolescent bed became available. Review of the daily psychiatric progress notes of 3/15/16 through 3/21/16 revealed that the patient continued to require inpatient psychiatric hospitalization and was still awaiting transfer to another facility for an open adolescent bed. The progress note by the psychiatrist on 3/22/16 at 11:42 noted that the patient was showing improvement, was not suicidal or homicidal, and not overtly psychotic and that the patient "can be treated as an outpatient." The physician recommended that the patient be discharged on [DATE]. The progress note stated that the patient's mother had no concerns about the discharge for that day. However the progress note did not mention if the mother was informed of the need for outpatient psychiatric follow-up care for patient #10.

Patient #10 had been discharged home later on 3/22/16 with discharge instructions that failed to indicate the need for the patient to follow-up with outpatient psychiatric services as noted on the discharge summary/progress note. The discharge instructions for the patient also failed to contain documentation about care instructions and/or training of the patient/family and also failed to list the medications that the patient had been administered and/or was to continue taking after discharge.

Failure to provide all patients with the necessary medical information about referrals for outpatient services and the need for follow-up care places patients at risk for delayed recovery and readmission with exacerbation of symptoms.