HospitalInspections.org

Based on review of hospital policy and procedures, review of medical records, and interviews with staff, the hospital staff failed to provide a language interpreter for a Spanish speaking patient according to hospital policy for 1 of 1 sampled patients requiring an interpreter. (Patient #1).

The findings include:

Review of policy titled, "Communication with Limited English Proficiency Patients and Families" with revision date of 10/2017 revealed " ...This policy addresses spoken (verbal) communication with Limited English Proficiency persons through the use of approved interpretation services or other language assistance methods. The goal of providing interpretation services is to deliver high-quality, consistent and appropriate information to patients, families and visitors to ensure that they have meaningful access to (named facility) services ....Policy: 1. (Named facility) provides access to qualified health care/medical interpreters. Interpreter services may be provided by: Employed staff interpreters, Contracted interpreters, Telephonic interpretation (over the phone) and video interpretation. ....Interpreter services must be available to all inpatient and outpatient clinical areas during all of their hours of operation ....If patients or their representatives insist on using a friend or family member to provide interpretation, (named facility) personnel will also retain a health care interpreter to participate in the encounter to ensure accurate information is presented to hospital staff and patients....(Named facility) emphasizes effective communication in the provision of medical, nursing and ancillary services where patient outcomes may be affected. Interpreter services will be used in all situations where the content of the communication is critical. The following types of encounters and procedures require the use of health care interpreter services .....Providing medication instructions and explanation of potential side effects ....Explaining any medical procedures, tests or surgical interventions ...Explaining any diagnosis and plan for medical treatment ...(Named facility) staff must document the use of interpreter service in the medical record. Documentation will include: 1) type of service (staff, telephone, video, etc), and 2) information to identify the interpreter (name, employee ID number) ...."

Closed medical record review of Patient #1 revealed an 87 year old Spanish speaking male admitted on 02/11/2019 for bleeding from the left ear. Review of the medical record revealed a past medical history of vascular dementia which caused confusion. Review of a Hospitalist (MD #1) progress note dated 02/12/2019 at 1318 revealed "...Review of systems: Patient with dementia, unable to get ROS (review of systems), confused...ENMT (ears, nose, mouth, and throat): dried blood external ear, patient is not cooperative with ear exam...Neuro: awake, confused, grossly nonfocal...Psych: confused....Disposition: Plan d/w (discussed with) patient and agrees, all questions answered." Further review revealed no documentation of interpreter services. Review of a nurse's (RN #1) discharge note dated 02/18/2019 at 1553 revealed "Discharge paperwork completed with patient and son. Copy of discharge instructions given to pt (patient)along with follow-up info (information). Pt verbalized understanding of all. No questions voiced...." Further review revealed no documentation of an interpreter being present.

Interview on 04/16/2019 at 1635 with MD #1 stated the patient did speak Spanish, and required assistance with language. Interview revealed no recollection of interpreter being present.

Interview on 04/17/2019 at 0920 with Coordinator of Language Services revealed there are language interpreters on site 24 hours a day and should have been present for all contacts with the patient. Further interview revealed only approved staff can function as interpreters.

NC00148796