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TRINITY HEALTH ANN ARBOR HOSPITAL
PATIENT RIGHTS: EXERCISE OF RIGHTS
Tag No.: A0129
Based on interview and record review, the facility failed to document the patient's communication preferences in a timely manner for 1 (P-1) of 2 patients reviewed requiring translation services resulting in the loss of patient rights and the increased likelihood of negative consequences for the patient. Findings include:
On 3/15/2025 at 1039, P-1 was admitted to the facility's Emergency Department.
On 3/15/2025 at 1128, P-1 signed their general consent and there was no documentation whether any interpreter was used.
On 3/16/2025 at 0215, P-1 was provided information on advanced directives and there was no documentation that an interpreter was used.
On 3/17/2025 at 1622, P-1's language status was changed in the medical record from English to Korean.
On 3/17/2025 at 1649, P-1's language preference for "written" was changed from English to Korean.
On 3/17/2025 at 1741, P-1 was discharged from the facility with after care instruction documentation in the Korean language.
On 3/20/2025 at 1106, three days after discharge, P-1's medical record was updated to reflect P-1's language for "spoken" was English.
On 4/16/2025 at 1645, Nurse Staff O was queried why they used an interpreter when discharging P-1, and they revealed that P-1 "spoke Korean." When queried if P-1 spoke English, Staff O revealed that they didn't "know how much" and "could say a few words." Staff O revealed that a family member shared that P-1 "doesn't understand English." Staff O proceeded to update P-1's medical record with P-1 requiring interpreter services.
According to the facility's policy "Patients - Communication Assistance (Limited English Proficiency (EP) , Sight, Impairment and Hearing Impairment.), dated 2/24, "Every attempt will be made during the admission process to determine the communication assistance needs of each patient. This need will be documented in the medical record. Documentation will include, as applicable, the patient's language and communication needs and authorized representative, if any. During high-risk communication, the presence of any interpreter must be documented in the medical record. The type of interpretation used as well as if the patient declines language interpretation services must be documented in the medical record. The policy also revealed "The following are examples, but not an all-inclusive list, of high-risk communications: providing information about advanced directives, obtaining informed consent or permission for treatment or surgery.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0173
Based on interview and record review, the facility failed to ensure an order for a restraint was initiated in a timely manner for 1 (P-5) of 4 patients reviewed for restraints resulting in the potential for negative consequences for the patient. Findings include:
On 4/17/2025 at 1100, during P-5's medical record review with Accreditation and Regulatory Program Leader Staff C, P-5 was placed in left and right wrist soft restraints on 4/13/2025 at 0000 for pulling lines and tubes. P-5's order for the restraint occurred on 4/13/2025 at 0814, over 8 hours after soft restraints were initiated on P-5. Staff C confirmed the findings at the time of discovery.
On 4/17/2025 at 1115, when queried how would you define as soon as possible for obtaining an order for restraints, Staff C revealed "one hour."
According to the facility's policy "Restraint Non-violent and Violent), dated 2/25, "Physician/LIP or Registered Nurse if the physician/LIP is not available, a registered nurse may initiate restraint in advance of a physician/LIP order. If the restraint was due to a significant change in the patient's condition, the physician shall be contacted as soon as possible for an order. If initiated by RN, notify physician/LIP to obtain an order as soon as possible."