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Based on interview and record review, the facility failed to provide an interpreter upon request from a family representative for 1 (#1) of 10 patients resulting in the potential loss of patient/representative rights and the potential to not make an informed decision. Findings include:

During an interview with Confidential Informant A on 4/6/2021 at 1148, it was stated Patient #1 was able to speak English; however, there was "a definite language barrier" for Patient #1's wife who only spoke Spanish and did not understand English at all. It was further stated that the adult daughter of Patient #1 was "left to translate" for her mother.

On 4/6/2021 at 1430, review of the medical record for Patient #1, the patient of concern, revealed he was a 69-year old male who came to the emergency department on 12/1/2020 with a chief complaint of shortness of breath and cough for one week after caring for his wife at home who was COVID positive. He was admitted to the hospital with a diagnosis of COVID-19 pneumonia with hypoxia (low oxygen in blood). The admitting nursing assessment dated 12/1/2020 indicated his wife was to be his "surrogate decision maker." It was noted there was no designation found in the medical record whether a language barrier was present for Patient #1's wife. The admitting history and physical (H&P) also dated 12/1/2020 stated Patient #1's "Concentration is poor. Patient has difficulty attending to conversation and train of thought..." Patient #1 was on high flow oxygen via nasal cannula initially. He was placed on Bipap (bilevel positive airway pressure) with 100% oxygen on the morning of 12/3/2020 and then moved to the intensive care unit (ICU) that same afternoon. Patient #1 indicated he did not wish to be resuscitated (DNR-do not resuscitate) nor intubated (DNI-do not intubate), and his daughter, who was on the phone, agreed.

Social work notes dated 12/8/2020 revealed the family was concerned about being unable to visit Patient #1 because of the COVID diagnosis. A video chat was offered but the family was unsure at the time if their technology would support the video chat. A video chat was finally accomplished on 12/15/2020.

On 12/16/2020 at approximately 1125, the physician contacted Patient #1's daughter to discuss Patient #1's condition and possible need for intubation. Patient #1's code status was confirmed at that time. A follow up dietician note dated 12/18/2020 revealed Patient #1 had lost approximately 40 pounds during his hospitalization and understood the need to eat; however, had difficulty "due to his breathing issues."

Further review of social work notes dated 12/17/2020 at 1125 revealed Social Worker Staff O documented a phone call from the daughter requesting the physician call with the benefit of a translator to discuss her father's care with her mother. Staff O also documented that instructions for translation were placed in a "sticky" note.

During an interview with Social Worker Staff O on 4/7/2021 at 1130, Staff O stated she did not recall the exact situation. She stated social workers were not always on site to set everything up for translation but they did try to empower staff by providing instructions on a "sticky note" in the medical record software. This became common practice since the beginning of the COVID pandemic and was something that all staff were familiar on accessing. Staff O further stated the "sticky note" was not kept as a part of the permanent record once a patient was discharged from the system. This was confirmed by the System Director of Safety and Quality Staff B on 4/7/2021 at 1140.

During an phone interview with Physician Staff M on 4/7/2021 at 1530, Staff M stated, "There was no major language barrier with the family. The patient understood and so did the daughter." When queried as to if he had seen the note by the social worker that the family was requesting an interpreter so a conversation could be had with Patient #1's wife who did not speak English, he paused, then said, "No. I didn't see that. I must have missed it...I talked to the daughter, but never talked to his wife."

Facility policy E-210 titled "Language Communication Policy" last revised April 2020 states, "All (facility name) Healthcare staff providing patient care are expected to be familiar with and follow the Language Communication expectations and procedures. Providers and staff should engage in an interactive process with the individual who requests accommodation in order to ensure effective communication is achieved. This policy applies to all employed staff and physicians, inclusive of those who are contracted or temporary."