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Based on document review and interview, it was determined that for 2 of 10 (Pt. #1 and Pt #6) clinical records reviewed, the Hospital failed to facilitate access to a Translator as required by policy. This has the potential to affect all patients who require translator services.
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Findings include:

1. On 08/22/23, the Hospital policy titled, "Patient Bill of Rights and Responsibilities (revised 01/30/23) was reviewed. The policy stated, "Policy:... III. To make choices and decisions. A. To be informed, in understandable terms and in a manner tailored to the patient's age and ability to understand, using the patient's preferred language or mode for healthcare communication, the nature of the patients's health care status, condition, proposed treatment or procedures and prognosis. B. To have language interpreters available at no cost to the patient. If a patient has vision, speech, hearing, language or cognitive impairments, the hospital will address those communication issues in a manner that meets the patient's needs."

2. On 08/23/23, the PowerPoint education titled, "Interpreter & (and) Translation Services Overview" was reviewed. The education required, "... Offer the Use of an Interpreter... to provide clear and effective communication during all medical conversations! Other key situations include, but are not limited to: Completing the 'Waiver/Refusal of Interpreter Services' form when patient declines use of (Hospital) provided services, registration, communicating with LEP (Limited English Proficiency)/ deaf parents or guardians, Discharge Instructions, Therapy sessions, Billing / insurance issues or financial applications... Epic Hyperspace Documentation Documenting all rows completely is vital: to show an interpreter was utilized for medical conversations, every time an interpreter is utilized, "

3. On 08/23/23, the policy titled, "Use of Interpreters, Translators, and Auxiliary Aids for Individuals with Communication Barriers" was reviewed. The policy stated, "Procedure:.... Part II. Interpreters and Translation for Limited English Proficiency Patients and Deaf and Hard of Hearing Patients.... C. Use of Family Members or Patient-Provided Interpreters.... 2. (Hospital) entities shall not rely on an adult accompanying an individual with Limited English Proficiency or who is Disabled to interpret or facilitate communications except as follows:... b. Where the individual specifically requests that the accompanying adult interpret or facilitate communications, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances (See Section C.5 below.)... 5. A patient shall not be required to utilize Language Assistance... services. If a patient declines a (Hospital) entity's offer of a Qualified Interpreter and instead requests that a family member, friend or other person ... be used to facilitate communication...a. Team Members shall document in the patient's electronic medical record that a Qualified Interpreter was offered and declined, and that the individual requested by the patient provided interpretive services...."

4. Pt. #1's clinical record was reviewed. Pt. #1 presented to the ED on 11/23/22 with a chief complaint of "post-op (operative) problem. Pt #1's record indicated Pt #1's spouse was utilized as an interpreter by ED physician (E #8). Pt #1's record did not document that Pt #1 was offered translator services and lacked completion of the "Waiver/Refusal of Interpreter Services" form.

5. On 8/23/2022 at 10:30 AM, an interview was conducted with the Risk Manager (E #2). E #2 stated, "The Communication Needs Assessment for (Pt #1) was not completed and should have been." E #1 also verbally agreed Pt #1's record did not indicate that Pt #1 was offered or refused interpreter services.

6. Pt # 6's clinical record was reviewed. Pt #6 was admitted on 8/7/23 with a diagnosis of abdominal pain. Pt #6's record indicated "Needs Interpreter: Kirundi, Rundi." A nursing note on 08/08/23 at 12:15 AM stated, "Translator (identifying translator number) utilized during admission assessment." The urology physician progress note by MD (E #12) on 08/09/23 at 10:24 AM stated, "... Review of Systems: Difficult to interpret secondary language barriers..." Pt #6's record lacked documentation of translator usage after the initial admission nursing assessment note. The record did not indicate the use of the translator at discharge.

7. On 8/23/2022 at 10:30 AM, an interview was conducted with Informatics RN (E #13). E #13 stated, "I do not see documentation that the interpreter services was utilized for discharge. The only documentation that I see is during the admission nursing assessment note. There should be documentation in the record and there is not." E #13 verbally agreed the record lacked documentation of interpreter services after the initial admission nursing assessment note.