HospitalInspections.org

Based on the review of one of 10 medical records (Patient (P)1), staff interviews, and review of facility documents, it was determined the facility failed to ensure that language interpretation services are utilized for all non-English speaking patients during their hospital admission.

Findings include:

Facility policy titled, "Language and Interpretation Assistance"(Revised 10/2023) states, "...[Name of Hospital] will ensure that patients with limited English proficiency have meaningful access to translation services ... Language assistance will be provided through use of translation/interpretation services with devices available on each patient care unit ... Procedure: Patient's preferred language is documented ... When a language other than English is listed as the patient's preferred language, the translation assistance device will be brought to the patient and the translator will be contacted to assist ... The Translator ID must be documented in the medical record at the time of service ... Language interpreter service should be contracted for, but not limited, to the following situations: Determination of the patient's medical history, description of why he/she came to hospital; Provision of information regarding patient rights, informed consent, or permission for treatment; Discussion regarding diagnosis, prognosis; Explanation of procedures, tests, treatments, treatment options ... Explanation of medications; Explanation of discharge instructions, including follow up ... Family members are not to be used to provide translation services. Only employees who have completed the NJHA (New Jersey Hospital Association) training program (Effective Communication in Healthcare Training for Bilingual staff) may translate in place of translation service. ... Refusal of Interpreter services: Patients have the right to refuse interpreter services. Documentation of refusal and reason why refused must be documented in the nurses and physician notes. ..."

On 05/15/25 at 10:04 AM, during the entrance conference with Staff (S)1, S2, and S3, S1 stated that patients are asked to identify their preferred language during hospital registration. S3 stated that language interpretation is available throughout the hospital via iPad (electronic device) and telephones utilizing "GLOBO Language Solutions" (Translation service). At 10:15 AM, S3 confirmed that nurses and technicians are expected to document every time the translation service is utilized in the patient's electronic medical record (EMR). S2 confirmed that staff are expected to utilize GLOBO for patients that require translation services, and each use is documented in the patient's medical record. When asked if families are ever used for language interpretation, S2 stated, "Staff should not use patient family members to translate, unless the patient insists."

During the review of P1's medical record on 05/15/25 at 12:10 PM, the following was revealed:

P1 arrived at the Emergency Department (ED) on 04/09/25 at 2:25 PM via EMS (Emergency Medical Services [ambulance]) with a chief complaint of "Palpitations (feeling of an irregular heartbeat)." The patient's Face Sheet indicated the preferred language was Spanish. The "General Information Consent and Authorization" document was written in Spanish and signed by P1 on 04/09/25 at 2:40 PM. P1 admitted inpatient on 04/10/25 at 4:55 AM with admitting diagnoses including generalized weakness and dehydration. P1 discharged home on 04/11/25 at 5:01 PM.

The ED History and Physical provider note written by S10 on 04/09/25 lacked documentation that GLOBO translation services was used, or that an NJHA trained staff provided language interpretation when he/she met with P1, in accordance with facility policy.

The Discharge Summary provider note written by S15 on 04/11/25 at 1236 (12:36 PM) lacked documentation that GLOBO translation services was used, or that an NJHA trained staff provided language interpretation when he/she met with P1, in accordance with facility policy.

On 05/15/25 at 1:00 PM, S4 confirmed that the provider notes lacked documentation that GLOBO translation services or NJHA trained staff provided language interpretation when providers met with P1 on 04/09/25 and 04/11/25.