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Based on review of 6 open and 4 closed records, and review of hospital policies and procedures, it was determined that the facility failed to follow their communication policy and provide patient #2 with an interpreter to ensure the patient was informed about, and involved in, their own care.

Per hospital policy "Communication Needs of Residents/Patients." Dated 9/18. "Family members may not act as interpreter for the resident/patient." Furthermore, "Procedure: 1. When a resident/patient chooses a language other than English for the health care encounter, interpreter services (Qualified Bilingual Interpreters Required) will be utilized to facilitate communication between the patient/resident and/or family and the health care team to ensure the resident/patient/family possesses an understanding of their care."

Patient #2 was a 75+ year old patient admitted to this facility from another hospital for management of a respiratory condition. It was documented throughout the record that the patient was Spanish only speaking. Review of the medical record revealed multiple documented entries that although the patient was on a ventilator, he/she was "awake, alert, oriented, interactive and motivated." The physician performing the History and Physical documented that the patient was awake and alert, however the physician also stated that they were "using a family member to translate for the patient." Nursing notes, Care Management notes, and a consult from the dietitian revealed the same results.

No documentation was found to support that an interpreter was used at any time to establish a baseline with the patient, to determine the patient's understanding of the treatment plan or to confirm the information that was given by the family was accurate.