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Based on record review and interview, the hospital failed to ensure each patient was informed of patient rights. This deficient practice was evidenced by failure to inform Patient #1 of their patient rights in a language or manner non-English speaking patients could understand.
Findings:

Review of hospital policy titled "Patient Rights and Responsibilities," effective date: 11/13/2023, revealed in part: III. Policy Statement B. Each patient/representative shall be informed of the Patient Rights and Responsibilities ...
IV. Policy Implementation
A. Patient Rights
1. Non-Discrimination. Every patient has the right to be provided services in a non-discriminatory manner. This Organization prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression in accordance with applicable federal and state laws and regulations.
4. Dignified, Respectful Care. Every patient has the right to receive care in an environment that preserves dignity, respects each patient's psychosocial, spiritual, and cultural values and beliefs, and contributes to a positive self-image. Further, every patient has the right to be cared for by providers and staff educated about patient rights and their own individual roles in supporting these rights.
5. Informed Care. Every patient has the right to be informed, in understandable terms and in a manner tailored to the patient's age, language, and ability to understand, of his or her health status, treatment, prognosis, plan of care, discharge, and follow-up in order to make decisions as to care. Every patient has the right to know the nature, risks and alternatives to treatment. The patient has the right to be informed, when appropriate, regarding the outcome of the care provided, including unanticipated outcomes.
20. Interpretation. The patient has the right to be provided with interpretation services if he or she does not speak English ... and to have any other resources employed on his or her behalf to ensure effective communication.
C. Admission and Hospitalization
1. During the admit process, patients/representatives shall be provided with a copy of the Patient Rights and Responsibilities.

Review of Patient #1's medical record revealed that the patient was Spanish speaking. Further review of Patient #1's medical record failed to reveal that the patient was informed of their patient rights.

During an interview on 10/02/2024 at 3:00 p.m., S4PIS and S5RN confirmed that there is no documented evidence that the patient was notified of their patient rights.

Based on record review and interview the hospital failed to ensure the Registered Nurse evaluated the care of each patient in accordance with accepted standards of nursing practice. This deficiency is evidenced by:
1) failure to document that an interpreter/translator was used to complete the Nursing Assessments and Provider Assessment, for non-English speaking Patient #1;
2) failure to document a reassessment on 2 (#1, #3) of 4 (#1-#4) patients as per policy.
Findings:

1) Failure to document that an interpreter/translator was used to complete the Nursing Assessments and Provider Assessment, for non-English speaking Patient #1.
Review of hospital policy titled, "Interpreter Services for Limited English Proficiency Patients," Effective Date 01/14/2021, revealed in part: V. Policy Implementation B. Interpreter Services are free of charge and available to patients 24/7 upon patient request of staff identification of the need for an interpreter. F. The choice of the patient with respect to accepting or declining interpreter services, the presence of an interpreter and the means through which the interpreter is provided (In-person, VRI or OPI) will be documented in the electronic medical record at each visit.

Review of Patient #1's medical record revealed documentation that the patient "Needs Interpreter: Spanish." Documentation also revealed that Language Interpreter accepted by patient. Further medical record review failed to reveal documentation that an interpreter/translator service was used to communicate with the patient by the nurse or provider.

During an interview on 10/02/2024, S5RN confirmed that there was no documentation that the nurse used an interpreter service for communication with Patient #1 who was Spanish speaking.

During an interview on 10/03/2024, S6EDRD confirmed that there was no documentation that the ED provider used an interpreter service for communication with Patient #1 who was Spanish speaking.

2) Failure to document a reassessment on 2 (#1, #3) of 4 (#1-#4) patients as per policy.
Review of hospital policy titled, "Emergency Department Assessment Standards," Approval Date: 1027/2023, revealed in part: C. Reassessment: 1. The frequency of the reassessment is based on the patient's acuity, condition, history and complaint, or as directed by the physician; minimally every 4 hours.

Review of hospital policy titled, "Assessment and Reassessment (Hospitalized Patients)," Effective Date: 12/13/2021, revealed in part: IV. Procedure G ... Patients will be reassessed at the following times: 2. Upon transfer, admit or discharge from another unit as set forth in this operational standard. 7. Within two hours of discharge.

Review of Patient #1's medical record revealed that Patient #1 arrived on 08/19/2024 at 4:49 a.m. by ambulance with complaints of Suicide. Patient #1 was triaged and a nursing assessment was documented on 08/19/2024 at 5:00 a.m. Patient #1 was transferred from the ED to another facility on 08/19/2024 at 1:20 p.m. Further review of Patient #1's medical record failed to reveal a reassessment documented on the Patient #1 by a nurse as per policy.

During an interview on 10/03/2024 at 11:17 a.m., S7EDS confirmed there is not a documented reassessment on the patient since initial assessment prior to departure.

Review of Patient #3's medical record revealed that Patient #3 arrived on 09/26/2024 at 1:33 p.m. with a complaint of Flu symptoms. Patient #3 was triaged and a nursing assessment was documented on 09/26/2024 at 2:22 p.m. Patient #3 was transferred from ED to another facility on 09/27/2024 at 12:15 a.m. Further review of Patient #3's medical record failed to reveal a reassessment documented on the Patient #3 by a nurse as per policy.

During an interview on 10/03/2024 at 10:17 a.m., S6EDRD and S7EDS confirmed there is not a documented reassessment on the patient since initial assessment prior to departure.