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Based on observation, interview, and record review the facility failed to ensure one (1) of thirty-two (32) sampled patients (Patient 12) had documentation of the interpreter's Identification (ID) number in the medical record.

This deficient practice had the potential to result in not meeting Patient 12's needs by not adhering to policy regarding non-English speaking patients by providing an interpreter for translation services (access to language assistance for patients which is key to the delivery of high-quality care for all populations with limited English proficiency) when needed.

Findings:

During a review of Patient 12's admission record, dated 9/17/2023, the admission record indicated, Patient 12's preferred language was Spanish.

During a review of Patient 12's informed consent (IC), titled "Consent for Blood Transfusion," translated into Spanish language, dated 9/18/2023, the IC indicated, Patient 12 signed the IC on 9/18/2023 at 00:30 A.M. The IC further indicated; no documentation of interpreter's ID was recorded.

During a concurrent interview and record review, on 9/19/2023, at 3:00 P.M., with Chief Nurse Executive/Administrator (CNO-A), Patient 12's informed consent, titled "Consent for Blood Transfusion" was reviewed. The informed consent indicated; Patient 12 verbally agreed to the terms of "Conditions of Admission" form. The informed consent further indicated the form, translated into Spanish language contained no documentation of Interpreter's Identification (ID) number. The CNO-A stated, facility's staff should document the ID number of the interpreter who provided translation services to Patient 12, but facility's staff did not.

During an interview on 9/20/2023 at 8:00 A.M., with Director of Nursing (DON), the DON stated, nurses should assess newly admitted patients and document their preferred language. The DON further stated, if a patient is a non-English speaking patient, staff should provide translator services and a primary language interpreter by using the facility's indicated device available on each unit. The DON also stated, staff should document the Interpreter's ID number in the medical record as per facility's policy.

During an interview on 9/20/2023 at 9:04 A.M., with emergency room nurse (Nurse 2), the Nurse 2 stated, per facility's policy, after using translator services, nurses document date, time and the ID number which is provided by the interpreter when their services are used.

During a concurrent interview and record review on 9/20/2023, at 10:00 A.M., with Director of Registration, Patient 12's consent for procedures, titled "Conditions of Admission (contract between the hospital and the patient)," dated 9/17/2023, was reviewed. The consent for procedures indicated the following terms: consent to medical and surgical procedures; nursing care, legal relationships between facility and physicians; release of information, personal valuables, financial agreement, assignment of insurance benefits, healthcare services, and patient's rights. The DR stated every patient who is admitted to the facility must sign "Conditions of Admission" form provided by the Registration Department personnel.

During a concurrent interview and record review, on 09/20/2023, at 10:00 A.M., with Director of Registration (DR), Patient 12's consent for procedures, titled "Conditions of Admission" dated 9/17/2023 was reviewed. The form indicated, Patient 12 verbally consented to translation into Spanish "Conditions of Admission" form, but no interpreter's ID was recorded. The DR stated the process for the registration personnel is to provide qualified interpreter services through the facility's available interpreter's equipment to non-English speaking patients. The DR further stated the practice of recording the interpreter's ID number in the medical record was not practiced by the Registration Department.

During a review of the facility's policy and procedures (P&P), titled "Language Interpreter Services and Special Needs for the Hearing and Sight Impaired," dated 12/2022, the P&P indicated, "The facility has an on-demand access to medically qualified interpreters in over 200 languages through a special equipment. Standard forms are available in Spanish. Utilization of a medical interpreter for communication of key medical information will be documented in the medical record. In the case of consent of surgery/procedure the "Interpreter Statement" contained in the consent shall be completed. The interpreter, staff, or physician shall enter a patient care note with the following information: interpreter name and or identification number, clinician's name, date of service, and brief description of interpreter's service. The employee is to document the interpreter's ID number in the medical record."

During a review of the facility's policy and procedures (P&P), titled Patient Consent and Informed Consent," dated 2/2023, the P&P indicated, "Consent for procedures that do not require informed consent is obtained through the Conditions of Admission. Consent for procedures that do require informed consent is obtained through the Authorization for and Consent to Surgery or Special Diagnostic Procedure form. Surgery and invasive procedure require a separate authorization, specifically the Authorization for Consent to Surgery or Special Diagnostic Procedure. Prior to the procedure consent form being signed, and it is the responsibility of the treating physician, or the physician performing the procedure to obtain informed consent."

During a review of the facility's policy and procedure (P&P), titled "Patient Rights and Responsibilities," the P&P indicated, "The facility guarantees specific patient rights that guarantee a patient's right of self-determination. Staff can access qualified and experienced medical interpreters to better meet the needs of Limited English Proficient (LEP) patients."

Based on observation, interview, and record review, the facility failed to maintain the operating rooms (ORs) within the acceptable range of 68 to 75 degrees Fahrenheit (a unit of temperature measurement) and failed to implement an effective method for monitoring the temperature in the ORs during surgery.

This failure had the potential to result in an increased risk of patients receiving surgical services at the facility contracting a surgical site infection (infection that occurs after surgery in the part of the body where the surgery took place).

Findings:

During an observation and interview, on 9/18/2023, at 4:18 P.M., with the Corporate Director of Plant Operations and Maintenance (DPO) and the Corporate Director of Safety and Security (CDSS), in the Maintenance Room, the Building Maintenance System (BMS, computer system used the by the facility to maintain and monitor temperature and humidity throughout the facility) display indicated that the following ORs were measuring at the following temperatures:

OR 1 – 67.66 degrees Fahrenheit

OR 2 – 64.72 degrees Fahrenheit

OR 3 – 67.76 degrees Fahrenheit

OR 4 – 67.81 degrees Fahrenheit

It was observed on the BMS computer screen, that the temperature of OR 2 was set at 65 degrees Fahrenheit. The DPO stated that the this was the system in place that the facility maintenance staff used to monitor the temperatures of the ORs in real time because the temperature of the ORs are taken one time in the morning by the facility ' s maintenance staff. The DPO stated that sometimes the surgeons or other surgical staff will request that the temperature is lowered below 68 degrees Fahrenheit per the policy.

During an interview and record review on 9/19/2023, at 1:30 P.M., with the CDSS and the Supervisor of Plant Operations (SPO) the CDSS stated that the policy titled "Air Temperature and Humidity Monitoring Policy #IC038," last revised on 01/2023, was the policy that the facility followed for the temperature range in the ORs. The policy indicates that the temperature of the ORs should be at 68 degrees Fahrenheit to 75 degrees Fahrenheit and not lower than 63 degrees Fahrenheit. The policy indicated that "Temperatures lower than 68 will be acceptable based on the risk assessment criteria which includes factors like the patient temperature being monitored and the humidity staying in an acceptable range. The lowest allowable temperature is 63." The SPO stated that the facility ' s maintenance staff has a record of when the surgical staff requests that the temperature is lower than 68 degrees per their professional recommendation.

During an interview and record review on 9/19/2023, 1:40 P.M., with the SPO, the SPO stated that the list titled "Log for OR Temperature Calls" date range from 9/6/2023 to 9/19/2023, was the complete list of times that the facility ' s maintenance staff had documented official requests from surgical staff for the temperature to be lowered below 68 degrees Fahrenheit. The log indicated that no documented evidence of requests for ORs to be lower than 68 degrees Fahrenheit existed for 9/18/2023. The SPO stated that the log did not include any request for the temperatures in the ORs to be adjusted on 9/18/2023.

During an interview on 9/19/2023, at 3:18 P.M., with the SPO, the SPO stated that the facility ' s maintenance staff relies on complaints from the surgical staff before the look at the BMS system to document and adjust the temperatures of the ORs.

During an observation and interview, on 9/19/2023, at 3:35 P.M., with the SPO and the Director of Surgery (DoS), in OR 1, the real time temperature according to the BMS system was reported to 67.62 degrees Fahrenheit. The facility ' s handheld Fluke thermometer (device used to measure temperature and humidity) measured the ambient temperature of the OR at 71.9 degrees Fahrenheit. The SPO stated that the temperature sensor of the BMS system was in the duct (tube) in the ceiling and that the temperature displayed on the BMS system was not an accurate way of measuring the temperature of the room because the BMS system may be as much as 3 degrees off. The DoS stated that the system in place (taking the temperature one time in the morning with the Fluke Thermometer and then relying on the surgical staff to complain about the temperature before alterations are made) is not an effective way to monitor and manage the temperatures of the ORs because the facility must rely on people ' s bodies to indicate that the temperature may be out of range.

During a concurrent interview and record review, on 9/19/2023, at 3:55 P.M., the DoS stated that the temperature range of 68 degrees Fahrenheit to 75 degrees Fahrenheit outlined in "Air Temperature and Humidity Monitoring Policy #IC038" last revised on 01/2023, should be maintained throughout the day and for every surgical procedure done in the ORs. The DoS stated that the temperature range should be monitored for all cases in the OR.

During a review of the untitled record indicating an hourly sampling of the temperatures in the ORs per the facility ' s BMS provided by the facility on 9/21/2023, dated 9/16/2023, 9/17/2023, and 9/18/2023, it was noted that 302 out of 306 recorded temperatures in ORs 1, 2, 3, and 4 fell below 68 degrees Fahrenheit.

During a review of the record titled "Log for OR Temperature Calls" date ranging from 9/6/2023 to 9/19/2023, it was noted that the record does not include any calls for approved temperature adjustments on 9/16/2023, 9/17/2023, or 9/18/2023.