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Based on interview, medical record review, contract reviews, map quest review, and review of the facility's policies, it was determined the facility failed to comply with 42.CFR 489.20 and 42 CFR 489.24(d) by failing to inform the individual(or the person acting on the individual's behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or the person acting on the individual's behalf) did not consent to the examination and/or both for one (1) of twenty-one (21) sampled residents, Patient #1, on 05/18/2022.


Refer to findings in Tag A-2407.

Based on interview, medical record reviews, contract reviews, map quest review, and review of the facility's policies, it was determined the facility failed to inform the individual(or the person acting on the individual's behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or the person acting on the individual's behalf) did not consent to the examination and/or both for one (1) of twenty-one (21) sampled residents, Patient #1, on 05/18/2022.


The findings include:

The facility's policy titled, "EMTALA - Medical Screening and Treatment of Emergency Medical Conditions", effective 12/02/2021, was reviewed. The section of the Policy titled, "D. Special Circumstances: Withdrawal of Request for Examination". The policy stated in part, "If a patient withdraws his or her request for examination or treatment, an appropriately trained individual from the emergency department staff should discuss the medical issues related to a voluntary withdrawal. In the discussion, the emergency department staff members should:
a. Offer the patient further medical examination and treatment as may be required to identify and stabilize and/or emergency medical condition.
b. Inform the patient of the benefits or the examination and/or treatment, and of the risks of withdrawal prior to receiving the examination and/or treatment; and
c. Use reasonable efforts to get the patient to sign a form indicating that the patient has refused the recommended examination and/or treatment. The form should contain a description of risks discussed, and if the examination and/or treatment that was refused."


Review of the facility's policy titled, "Procedure for Communication with Persons of Limited English Proficiency", revised 04/2019, revealed it was the facility's policy to provide communication aids to patients or families at no cost. The policy further identified use of (Name of Interpretive services-contract) Instant Remote Interpretation Services (IRIS) application for video and audio translation. Additionally, the policy identified a Language Line on the phone for use in interpreting over one-hundred forty (140) languages. The policy further stated, in addition to the interpreter through IRIS, patients might choose to rely on a family member or friend to translate instead of IRIS.

Review of the facility's contract with (Name of Interpretive services), last reviewed 01/16/2019, revealed, although the contract did include face-to-face ASL interpreting, it was a scheduled service and was not an on-call service.

Review of the facility's contract with (Name of Interpretive Services), signed 07/10/2015, revealed ASL interpreters were available in addition to Spanish interpreters. However, the contract indicated interpreter services were scheduled and were not an on-call service.

Review of ED documentation for Facility #1 revealed Patient #1 arrived with the spouse in their personal vehicle and presented to the ED with stomach pain at 6:53 PM on Wednesday 05/18/2022. According to medical record review Patient #1's spouse had called ahead for Patient #1, who was deaf and visually impaired, and requested an in-person American Sign Language (ASL) interpreter due to Patient #1's visual impairment. When an in-person ASL interpreter was not available, Patient #1 and the spouse became upset and refused to be triaged or to be provided a medical screening examination (MSE) without an in-person ASL interpreter present. The facility had not found an in-person ASL interpreter by the time Patient #1 left the facility, approximately thirty (30) minutes after arrival.

Further review of the ED documentation revealed that Patient #1 and the spouse refused to come back to triage without a sign language interpreter physically present in the facility. Patient #1 was deaf and visually impaired due to recent surgery, per the spouse. The IRIS ASL with video interpreter was utilized to communicate to patient and spouse as no physical person was available at facility to use for ASL interpretation. Per the documentation, Patient #1's spouse became upset, and the Administrator-on-Call (AOC) explained to the spouse that she had attempted to find a person to come to the facility to interpret live; but no one was available. Patient #1 and the spouse continued to express dissatisfaction, began using curse words, and stated they were leaving to go to another hospital. The documentation stated the AOC explained she felt they had been communicating with each other via the IRIS ASL video interpreter. The AOC stated the facility was able to see Patient #1 for evaluation and treatment. At that point, the record stated Patient #1's spouse used more curse words and said they were leaving. The record stated the spouse pushed the IRIS iPad out of his/her path with his/her foot and left Facility #1 with Patient #1 at 7:25 PM. There was no documentation in the medical record by Facility #1 that the risks and benefits of leaving were discussed with Patient #1 and the spouse. In addition, the record revealed no documents/forms were signed by Patient #1 and/or the spouse, indicating the patient had refused the recommended examination and treatment as stated in the facility's policy. Facility #1 documented Patient #1 eloped.


Review of Facility #2's ED documentation revealed Patient #1 arrived at the ED, on 05/18/2022 at 8:21 PM, with a chief complaint of flank pain and was admitted at 8:59 PM. The historian was listed as the patient and the spouse, with assistance by a sign language interpreter. Patient #1's Computed Tomography (CT) scan of the Abdomen and Pelvis without intravenous (IV) contrast was done on 05/18/2022, with results reported on 05/19/2022. The results indicated mild right-sided hydronephrosis (the swelling of a kidney due to build up of urine. www.kidney.org) and perinephric standing (a nonspecific sign pointing to an underlying inflammatory problem with the kidney. https://radiopaedia.org) with a stone in the proximal right ureter, maybe two (2) abutting stones measuring approximately 6.4 x 6.8 millimeters (mm) in diameter and a 3.4 mm non-obstructing stone in the lower pole of the left kidney. Patient #1 received a Right Ureteroscopy and Laser Lithotripsy with Stent Placement and was discharged on 05/20/2022 at 9:44 PM.



Interview with Registered Nurse (RN) #1, on 06/24/2022 at 3:06 PM, who was the Charge Nurse at the time Patient #1 arrived, revealed she had taken the incoming call from Patient #1's spouse, who had stated Patient #1 and the spouse were en-route to Facility #1. She stated the spouse stated Patient #1 was deaf and needed an in-person translator. RN #1 stated she told the spouse the facility would take care of Patient #1 and provide them a translator. RN #1 stated the facility did not have anyone in-house that could medically and legally translate, but had the IRIS system, which was what facility used. RN #1 stated Patient #1 and the spouse arrived to the ED, on 05/18/2022 at 6:45 PM. She stated this was when she was getting ready to leave, and she documented at that time that Patient #1 was also visually impaired. RN #1 stated Patient #1 was seated in a chair in the waiting area, when the spouse came to the registration window. RN #1 stated she attempted to convince the spouse to allow Patient #1 to go to triage so the patient could be assessed, and vital signs obtained. However, she stated the spouse, who appeared to be able to communicate with Patient #1, would not let Patient #1 go to triage until a live translator was in-house. RN #1 stated this surprised her as the spouse had sounded very anxious over the phone. RN #1 stated, while waiting on a translator, Patient #1 could have been seen by the doctor. RN #1 stated she explained the facility's policy, which she referenced during her conversation with Patient #1's spouse, was to utilize the IRIS. RN #1 stated Patient #1 did not appear to be in any distress, exhibiting no sounds or non-verbal cues to indicate Patient #1 was in any pain. RN #1 stated the family left without seeing a provider and left without being triaged.

Interview with the Registrar, on 06/24/2022 at 3:33 PM, revealed the spouse of Patient #1 came to the window in the ED, wrote down that Patient #1 needed an interpreter, and Patient #1 needed to be seen. The Registrar stated she wrote "okay", and wrote information needed to get Patient #1 registered. The Registrar stated she informed the spouse the facility used a program on iPad (a computer tablet) for interpreters, and the spouse said they preferred a live interpreter. The Registrar stated she shared this information with the house supervisor. After getting them registered, she stated, the House Supervisor (RN #1) came down to speak with Patient #1 and the spouse. The Registrar stated she had no more interaction with them. Per the Registrar, she heard the House Supervisor explaining that IRIS was the best Facility #1 could do. The Registrar stated she thought Patient #1 and the spouse had arrived at the ED later at night, and Facility #1 could not get a live interpreter. The Registrar reported that Patient #1 and the spouse were really upset, using curse words aimed at the House Supervisor. The Registrar stated the House Supervisor apologized that Facility #1 could not get a live interpreter. The Registrar stated Patient #1's spouse then came up to the window and told her they were leaving, and they left.

Interview with Patient #1's spouse, on 06/25/2022 at 9:31 AM, revealed Patient #1 had been experiencing abdominal pain for about two (2) days; and they had called the doctor, but an appointment was not available. The spouse stated Patient #1 was in pain, so they called Facility #1's ED and were instructed to come in. The spouse stated he/she informed staff an in-person interpreter was needed, and staff agreed to provide this. The spouse stated he/she informed ED staff that Patient #1 was deaf but did not mention the patient was visually impaired. The spouse stated when they got to Facility #1's ED, they were provided a video remote interpreting (VRI) screen. The spouse stated he/she told staff he/she had a VRI (Video Remote Interpreting-refers to reaching a language or ASL interpreter over a video phone call-amnhealthcare.com), and it was not reliable. The spouse stated he/she said they really needed a live interpreter because Patient #1 could barely see the screen. The spouse stated staff called someone (Director of Quality (DQ), who was the AOC), and the spouse told her they needed an in-person interpreter because of the patient's very limited eyesight. The spouse stated the AOC said staff had called four (4) different interpreting agencies. However, the AOC stated no one was available, which. the spouse stated surprised him/her as someone was always available. The spouse stated Patient #1 remained in pain, the spouse was upset, and the spouse told staff they needed to get an in-person interpreter. Per the interview, the spouse stated because Patient #1 could not communicate with Facility #1's staff, he/she pushed the VRI screen away. The spouse stated he/she asked Patient #1 if the patient wanted to go to another hospital, and the patient said "okay". The spouse stated then they drove forty-five (45) minutes to Facility #2. Additionally, the spouse stated hospitals were required to hire in-person interpreters for such delicate situations. The spouse stated he/she understood that VRI was an option until an in-person interpreter could get to the facility.

Review of the website MapQuest, https://www.mapquest.com, revealed Facility #1 was approximately nineteen (19) miles and thirty-nine (39) minutes from Facility #2, an acute care hospital.

Interview with the Nursing Director for the ED, on 06/27/2022 at 8:23 AM, revealed his understanding of the situation was Patient #1's spouse called ahead and stated they would need an interpreter, which the facility could provide through IRIS with ASL video. He stated, when Patient #1 and the spouse arrive at the ED, they expected, wanted, or preferred an in-person interpreter, which the facility did not have on-site. He stated the AOC made attempts to locate an interpreter to come in but did not have any luck. The Nursing Director stated he did not know whether or not Patient #1 could use the IRIS, although he believed they were able to communicate with Patient #1's spouse through the IRIS. The Nursing Director stated the family became angry, upset, and left when the facility was unable to provide them an in-person interpreter. He stated the ED offered the patient services they had available at the time and were attempting to meet their needs with an in-person interpreter. The Nursing Director stated IRIS was the main tool for the facility, to include the ED, for communication difficulties. He stated the facility did not employ an interpreter because the facility did not have the volume of larger hospitals in the area. He stated, during his time at the facility, he was not aware of any complaints about the IRIS. The Nursing Director stated it was his expectation that the facility would do whatever it could to meet the needs of the patients, so that they received good care. He revealed, his expectation regarding EMTALA, was the facility follow it to the letter of the law. He stated all staff members that worked in the ED received yearly EMTALA training.

Interview with the AOC/DQ, on 06/27/2022 at 8:44 AM, revealed she was the AOC the evening of 05/18/2022. She revealed she received a call from RN #1 regarding a prospective patient whose spouse had called and stated they would need an in-person interpreter. The AOC/DQ stated she advised RN #1 to utilize the IRIS until she could find another resource. The AOC/DQ stated the facility's contracts did not have a provision for an on-call interpreter, so she searched the Internet for any resources. She stated, of four (4) resources located within an hour or so of the facility, most did not have after hours call centers. She stated she finally reached a Chief Executive Officer/Owner (CEO) of a support service; however, as the facility did not have a contract with them, they could not provide services. The AOC/DQ revealed she kept searching for resources when she received a call from RN #3 who stated Patient #1 wanted to speak with her. The AOC/DQ stated she explained to Patient #1 and the spouse the facility was trying to get an in-person interpreter but had not yet been successful, and if they could keep using the IRIS to communicate, she would continue working to get an interpreter. The AOC/DQ stated the spouse told her they would just go to a nearby town where they knew they had an interpreter on-site. DQ stated she felt like they were communicating, but it was not what Patient #1 and the spouse wanted, and they ended up leaving before an interpreter could be located. The AOC/DQ stated they had never had anyone ask for in-person interpretation services through the ED, although the facility was able to provide scheduled in-person interpretation services. She stated this was the first time anyone had not been agreeable with using the IRIS and wanted a face-to-face interpreter.

Interview with the acting Medical Director, on 06/27/2022 at 2:47 PM, revealed he had limited knowledge of the incident on 05/18/2022, only what had been shared with him by the DQ. He revealed his expectation was patients who presented to the ED be provided a MSE and be treated accordingly. He stated ED staff received annual EMTALA training. Regarding patients that entered the ED with communication barriers, he stated his expectation was that staff "meet them where they are", whether that be through a communication board, a tablet, or virtual translators through interpretive contract. He stated if someone were to come in and could not utilize the facility's system, he would expect staff to attempt to contact a translator, although he expressed it might require advance planning. He stated the response time for an in-person translator was not as instantaneous as the tablet.

Interview with RN #3, the oncoming House Supervisor, on 06/27/2022 at 4:02 PM, revealed when she came on shift, the day shift House Supervisor (RN #2) said Patient #1 came to the facility and had called ahead requesting an in-person ASL translator. RN #3 stated RN #2 reported she had reached out to the AOC/DQ regarding this. RN #2 stated she received a call from RN #1, who asked if she would come down and speak with Patient #1 and the spouse. RN #3 stated the spouse was upset no interpreter was present and was refusing to let Patient #1 be triaged with the IRIS interpreter. RN #3 stated she linked with the IRIS video interpreter and explained the situation to the interpreter, stating the facility did not have an in-person interpreter at the moment. RN #3 stated she went to the lobby with the video interpreter, and as soon as she greeted Patient #1 and the spouse, they were instantly upset, shaking their heads, and signing with the video interpreter. The video interpreter said the sign language from the couple indicated it was not acceptable to use video interpreter. RN #3 stated she asked Patient #1 and the spouse to go to a room for privacy, but they refused. RN #3 stated she called the AOC/DQ for a three (3)-way conversation. RN #3 stated the AOC/DQ shared with the family the difficulty the facility was having getting an in-person interpreter. RN #3 stated the spouse was upset, and she again pointed out staff could triage Patient #1 to see what was going on with his/her abdominal pain. RN #3 stated the spouse then took his/her toe and pushed the IRIS machine past him/her and said they were leaving, going to another hospital, and would not be back to Facility #1.