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.

ADVENTIST HEALTHCARE SHADY GROVE MEDICAL CENTER 9901 MEDICAL CENTER DRIVE ROCKVILLE, MD 20850 Feb. 19, 2019
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on a review of Patient Rights documents given to patients, it was determined that the hospital failed to inform patients on how to file a grievance.

Review of patient admission materials revealed no process by which the hospital informed patients on how to file a grievance. While a review of actual grievances revealed a proactive process, no evidence of patient information related to grievance processes was found.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on a review of hospital policy "Consent" Revised 1/15/2019 and 7 open and 5 closed records, it was determined that for patients #4, and #7, no certification of incapacity was found prior to providers seeking consent from surrogate decision makers.

Review of hospital policy "Consent" Revised 1/15/2019 revealed in part, "POLICY: It is the right of every patient, in collaboration with his/her provider to make informed decisions about medical treatment that reflects his/her wishes."

Patient #4 was a 70+ patient admitted in February 2019 due to shortness of breath. Patient #4 spoke a dialect for which two attempts at translation service failed to communicate effectively, so the hospital used family interpretation.

Patient #4 required a procedure for which consent was needed. No incapacity statement was found in the record related to evaluation for patient #4's ability to make decisions. Instead, the consent for the procedure was signed by the family member who was acting as an interpreter. The Consent of 2/11/19 at 4:11 pm had a pre-printed section which stated, "If the patient is a minor, has mental incapacity, or unable to give consent, complete this section:" and, "I further certify that the patient is unable to give consent because: The family member write, "(patient) is too weak," and under a pre-printed statement "The procedure was explained to me, and I am authorized to consent for him/her because." The family member response to the statement indicated that the signing surrogate was the (family).

The hospital failed to utilize the only effective interpreter to help assess patient #4's understanding of the consent, or certify patient #4's incapacity status prior to obtaining consent from patient #4's surrogate.

Patient #7 was a 70+ patient who presented to the hospital in February 2019 due to a fall with fracture. Patient #7 was known to have some cognitive deficits, though at least two physician notes found patient #7, " ...with possible dementia, but currently pt is oriented with good insight," and, " ...with dementia, but currently pt is oriented with good insight."

A surgical consent the following day at 0730 revealed the pre-printed portion in part as, "If the patient is a minor, has mental incapacity, or unable to give consent, complete this section" "I further certify that the patient is unable to give consent because: The surrogate wrote, "Of confusion." The consent further stated, "The procedure was explained to me, and I am authorized to consent for him/her because:" The surrogate wrote, "I am his (significant other)." No actual capacity assessment was found which certified patient #7 to lack capacity prior to obtaining consent from patient #7's surrogate.

Following review of documentation for patients #4, and #7 it was demonstrated that while the hospital had a comprehensive and instructive Consent policy, hospital providers failed to meet regulatory requirements related to assessments for capacity prior to seeking surrogate decision-making.