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Based on interview, record review, and review of the facility's policy, it was determined the facility failed to inform each patient of his or her rights in a language or manner the patient understood for one (1) of twenty-one (21) sampled patients, Patient #1.

Patient #1 presented to the Emergency Department (ED), on 05/18/2022, with abdominal pain. Patient #1 was deaf and visually impaired. The facility provided Instant Remote Interpretation Services (IRIS) equipment, which was visible via an iPad screen, and IRIS had an American Sign Language (ASL) interpreter. However, the facility could not communicate with Patient #1 in a manner he/she could understand, using this service, because the patient was unable to see the interpreter on the screen. Patient #1 required an in-person ASL interpreter to communicate with the facility, which the facility did not provide.

The findings include:

Review of the facility's policy titled, "Patient Rights and Responsibilities", revised 06/2017, revealed the facility provided a comprehensive approach to protecting and supporting the rights of all patients by addressing their needs and requests, as well as the needs and requests of the families and/or guardians. The policy defined patient rights to include reasonable access to care regardless of race, creed, age, national origin or sources of payment, although it did not specify disabilities. Per the policy, a further defined right was an interpreter when the patient did not speak the predominate language of the community. Under a section on Communication, it stated when a patient did not speak or understand the predominate language of the community, he/she would have access to an interpreter at no cost to the patient. Under the section on Rights Upon Admission, the policy defined patients as having the right to be informed of their rights.

Review of the facility's policy titled, "Procedure for Communication with Persons of Limited English Proficiency", revised 04/2019, revealed it was the facility's policy to provide communication aids to patients or families at no cost. The policy further identified it used Language Services Associates Instant Remote Interpretation Services (IRIS) application for video and audio translation. Additionally, the policy identified a Language Line on the phone for use in interpreting over one-hundred forty (140) languages. The policy revealed, in addition to using an interpreter through IRIS, patients might choose to rely on a family member or friend to translate instead of IRIS.

Review of the facility's contract with Language Services Associates, last reviewed 01/16/2019, revealed, although the contract did include face-to-face ASL interpreting, it was a scheduled service and was not an on-call service.

Review of the facility's contract with Central Kentucky Interpreter Referral, Inc., signed 07/10/2015, revealed ASL interpreters were available in addition to Spanish interpreters. However, the contract indicated interpreter services were scheduled and were not an on-call service.

Review of Patient #1's ED record revealed, on 05/18/2022 at 6:53 PM, Patient #1 arrived at the ED with the spouse in a personal vehicle. Patient #1's chief complaint was stomach pain. Per the record, Patient #1 and the spouse refused for the patient to be triaged (assessed) without a sign language interpreter physically in the facility. The record stated, per the spouse, Patient #1 was deaf and visually impaired due to recent surgery. The IRIS ASL, with a video interpreter, was utilized in an attempt to communicate with the patient and the spouse because no on-site physical person was available to use for ASL interpretation. The record stated Patient #1's spouse was upset, and the Administrator-on-Call (AOC) explained that she had attempted to find a person to interpret live at the facility, but no one was available. Per the record, Patient #1 and the spouse continued to express dissatisfaction and stated they were leaving to go to another hospital. Per the record, the AOC explained that she felt staff had been able to communicate with Patient #1 via the IRIS ASL video interpreter, and the facility would be able to see the patient for evaluation and treatment. The record stated Patient #1's spouse told staff he/she and the patient were leaving, pushed the IRIS iPad out of his/her path with his/her foot, and left the ED with Patient #1 at 7:25 PM. The facility documented Patient #1 had eloped; however, the documentation was not signed.

Interview with Registered Nurse (RN) #1, on 06/24/2022 at 3:06 PM, revealed she was the Charge Nurse on duty in the ED when Patient #1 arrived at the ED, on 05/18/2022 at 6:45 PM. She stated she had previously taken the incoming call from Patient #1's spouse, who had stated the patient and spouse were en-route to the hospital. The spouse also stated Patient #1 was deaf and needed an in-person interpreter. RN #1 stated the ED would care for Patient #1 and provide an interpreter. RN #1 stated the facility did not have anyone in-house that could medically and legally translate; but, the facility used the IRIS system to provide an ASL interpreter for deaf patients. RN #1 stated Patient #1 and the spouse arrived when she was preparing to leave, and she documented, at that time, that Patient #1 was also visually impaired. RN #1 stated Patient #1 was seated in a chair in the waiting area, when the spouse came to the window. RN #1 stated she attempted to convince the spouse to allow Patient #1 to be triaged, so the patient could be assessed and vital signs (blood pressure, temperature, respiratory rate, heart rate) obtained. However, she stated the spouse would not let Patient #1 be triaged until an interpreter was in-house. RN #1 stated the spouse appeared to be able to communicate with Patient #1, and she was surprised that the spouse would not allow the patient to be triaged, as the spouse had sounded very anxious over the phone. RN #1 stated, while waiting on an interpreter, Patient #1 could have been seen by the Physician, but the spouse would not allow that until there was an interpreter in the building. RN #1 stated she referenced facility policy, which directed her to utilize the IRIS. RN #1 stated Patient #1 did not appear to be in any distress, with no sounds or non-verbal cues to indicate Patient #1 was in any pain. RN #1 stated Patient #1 and the spouse left without the patient seeing a provider or being triaged.

Interview with the Registrar, on 06/24/2022 at 3:33 PM, revealed Patient #1's spouse came to the registration window in the ED and wrote down that the patient needed an interpreter and needed to be seen. The Registrar stated she wrote down "okay" and the information needed the spouse gave to her to get Patient #1 registered. She stated she informed Patient #1's spouse the ED used a program on iPad for interpreters, to which the spouse replied that Patient #1 preferred a live interpreter. The Registrar stated she shared this information with the House Supervisor. After she registered Patient #1, she stated the House Supervisor (RN #1) came to speak with Patient #1 and the spouse. The Registrar stated she had no more interaction with them until the spouse of Patient #1 came to the window and told her they were leaving, which Patient #1 and the spouse did.

Interview with Patient #1's spouse, on 06/25/2022 at 9:31 AM, revealed Patient #1 had been experiencing abdominal pain for about two (2) days. The spouse stated he/she called the ED and was instructed to come to the ED for Patient #1 to be seen. The spouse stated he/she informed staff that an in-person interpreter was needed, and staff agreed to provide this. The spouse stated on the phone call, he/she informed ED staff the patient was deaf but did not mention the patient was visually impaired. The spouse stated when Patient #1 and the spouse arrived at the ED, they were provided a video remote interpreting (VRI) services screen (iPad). The spouse stated he/she told staff he/she had a VRI interpreter, and it was not reliable. The spouse stated he/she told staff the patient really needed a live interpreter because Patient #1 could barely see the screen. The spouse of Patient #1 stated he/she spoke with another staff member (Director of Quality (DQ)/AOC) who said she had called four (4) different interpreting agencies, and no one was available to physically come to the facility. The spouse stated Patient #1 was in pain, he/she was upset, and he/she told the DQ/AOC that the facility needed to get an on-site interpreter. The spouse stated, as the patient could not communicate using the VRI screen, the spouse pushed it away. The spouse stated he/she then asked the patient if the patient wanted to go to another hospital, and Patient #1 told the spouse "okay". So, the spouse stated he/she and Patient #1 drove forty-five (45) minutes to another facility's ED. The spouse stated he/she understood that video relay (VRI) was an option until an interpreter could get to the hospital. However, the spouse stated hospitals were required to hire in-person interpreters for such delicate situations.

Interview with the Director of Quality (DQ), on 06/27/2022 at 8:44 AM, revealed she was the AOC on the evening of 05/18/2022. She stated she received a call from RN #1 regarding a prospective patient who had called and stated he/she would need an in-person interpreter. The DQ stated she advised RN #1 to utilize the IRIS until she could find another resource. The DQ stated the existing facility contracts did not have a provision for an on-call interpreter, so she searched the internet for any resources. She revealed of four (4) resources within an hour or so of the facility, most did not have after-hour call centers. She stated she finally spoke with a Chief Executive Officer/Owner (CEO) of a support service; however, as the facility did not have a contract with them, they could not provide services. The DQ stated she kept searching for resources when she received a call from RN #3, who stated Patient #1 wanted to speak with her. The DQ stated she communicated with the spouse via IRIS, and the spouse used sign language to communicate with Patient #1. She stated she communicated that the facility was trying to get an in-person interpreter but had not yet been successful, and if they could keep using IRIS to communicate, she would continue working to get an in-person interpreter. The DQ stated the spouse told her Patient #1 and the spouse would just go to a larger facility in another city where he/she knew there was an interpreter on-site. The DQ stated she felt like staff was communicating with the spouse through IRIS, and the spouse was communicating with Patient #1 with sign language. However, the DQ stated she believed this was not what Patient #1 and the spouse wanted, because they ended up leaving before an interpreter could be located. The DQ stated, as far as she knew, the facility had never had anyone ask for in-person interpretation services through the ED, although the facility was able to provide scheduled in-person interpretation services. She stated this was the first time anyone had not been "okay" with using IRIS and wanted a face-to-face interpreter.

Interview with the acting Medical Director, on 06/27/2022 at 2:47 PM, revealed his expectation was patients who presented to the ED be provided a Medical Screening Examination (MSE) and treated accordingly. Regarding patients that entered with communication barriers, he stated his expectation was that "we meet them where they are, whether that be through a communication board, a tablet, or virtual translators through interpretive contract". He stated if someone were to come in and could not utilize the facility's system, he would expect facility staff to attempt to contact a translator, although he expressed it might require advance planning through the facility's existing contracts. He stated the response time for an in-person translator was not instantaneous as the tablet was.

Interview with the ED Nursing Director (ND), on 06/27/2022 at 3:23 PM, revealed IRIS was the main tool for the facility, to include the ED, for communication difficulties. He stated the facility did not employ an interpreter because the facility did not have the volume of the larger hospitals in the area. He stated, during his time at the facility, he was not aware of any complaints about the IRIS service. The ND stated it was his expectation that the facility would do whatever it could to meet the needs of the patients, so that they could receive good care.

Interview with RN #3, the oncoming House Supervisor, on 06/27/2022 at 4:02 PM, revealed when she came on shift, the day shift House Supervisor said Patient #1 had come to the ED and had called ahead requesting an in-person ASL translator. RN #3 stated RN #1 reported she had reached out to the AOC, the DQ, regarding this. RN #3 stated she received a call from RN #1, who asked if she would come down and speak with Patient #1 and the spouse. RN #3 stated the spouse was upset because no interpreter was present and was refusing to let Patient #1 be triaged with the IRIS interpreter. RN #3 stated she linked with the IRIS video interpreter and told the interpreter what was occurring and that the facility did not have an in-person interpreter at the moment. RN #3 stated she went to the ED lobby with the video interpreter, and as soon as she greeted Patient #1 and spouse, they were instantly upset, shaking their heads, and signing. RN #2 stated the video interpreter saw this and interpreted as them signing it was not "okay"; but, they did not use sign language to say why it was not acceptable. RN #3 stated she asked Patient #1 and the spouse to go to a room for privacy, but they refused. RN #3 stated she called the AOC for her to communicate with the spouse, and the AOC communicated with the spouse via IRIS, and the spouse used sign language to communicate with Patient #1. She stated the AOC communicated the difficulty the facility was having getting an in-person interpreter. RN #3 stated the spouse was upset, and RN #3 stated she again pointed out to the spouse that staff could triage Patient #1 to see what was causing the patient's abdominal pain. RN #3 stated the spouse then took his/her toe, pushed the IRIS machine past him/her, and said Patient #1 and the spouse were leaving to seek care at another hospital and would not be back to the facility.