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Based on interview and record review, the hospital failed to ensure patient's right to be informed for one of two patients, Patient (Pt 12), when Pt 12 was admitted to the hospital with complex diagnoses including sepsis and was assessed to require interpreter services and the electronic medical record did not accurately reflect whether nursing staff utilized interpretive services in accordance with professional standards of care and the hospital's policy and procedure.

These failures had the potential for patients with non-English language preferences to inadequately receive or understand medical procedures and educational information provided to them which could result in negative health outcomes

Findings:

During a review of Pt 12's Patient Demographics (PD) (document providing demographic information about the patient to include name, date of birth, admission date, emergency contact and more), dated 8/20/25, the PD indicated Pt 12 was a 65-year-old female arrived to the emergency Department (ED) on 8/16/25 at 8:28 a.m., was admitted to the ED on 8/16/25 at 8:34 a.m., and admitted as inpatient on 8/16/25 at 4:14 p.m. with admission reason as Sepsis (a life-threatening emergency caused by the body's extreme, uncontrolled response to an infection, leading to widespread inflammation, tissue damage, organ failure, and potentially death). The PD indicated Pt 12 " ... preferred spoken language: Spanish, Interpreter Needed? Yes ..."

During a concurrent interview and record review with 8/20/24, at 1:30 p.m., with the Manager of the Emergency Department (MED) 1, Electronic Medical Record (EMR) for Pt 12 were reviewed. The document titled, "Emergency Department Patient Care Timeline" (EDTL) indicated Pt 12 arrived at the Emergency Department (ED) on 8/16/25 at 8:28 a.m. and was admitted as an inpatient on 8/16/25 at 4:14 p.m. the EDTL indicated Pt 12 was Spanish Speaking and needed interpreter services. The document titled, "History and Physical" (H&P) dated 8/16/25 at 8:47 a.m. indicated Pt 12 " ... is a 65 y.o. (year old) female with cirrhosis, history of hepatic encephalopathy (a serious, potentially reversible neurological condition caused by a buildup of toxins in the blood due to advanced liver disease or liver failure, which prevents the liver from filtering them properly) ..." The document titled, "Interpreter Flowsheet" (IFS) dated 8/16/25 to 8/20/25 was reviewed, the IFS indicated on 8/16/25 Interpreter was used with name as "start", location as "start". The IFS indicated on 8/17/25 interpreter was used with no documentation of the interpreter ' s name, interpreter session type, interpretation provided to, and interpretation location. The IFS indicated that from 8/18/25 to 8/20/25 there was no documentation if an interpreter was needed, the interpreter type, interpretation method, interpreter name, interpreter session type, interpretation provided to, and interpretation location. MED 1 stated that while family members may assist with basic communication such as bathroom requests, they should not be used as interpreters for medical situations. MED 1 stated the Licensed Nurse (LN)s are expected to document the interpreter ' s name in the Pt 12 ' s medical records as part of standard protocol. MED 1 stated Pt 12 required professional interpreter services to ensure comprehensive understanding of her treatment plan and care instructions. MED 1 stated failing to provide proper interpreter services could result in Pt 12 or family members giving uninformed consent or experiencing confusion about medical procedures and treatments they do not fully understand.

During an interview on 8/21/25 at 1:08 p.m., with the Manager Interpreter Services (MINTS), the MINTS stated the hospital provides 24/7 interpreter services, which include iPad (portable electronic device where the interpreter was called from) devices for remote interpreter access and bilingual tiered (certified medical interpreters trained professionals who can translate health information correctly) staff. The MINTS stated the hospital uses a two-Tiered process, Tier 1 staff for conversational communication only and Tier II staff for medical communication and complex healthcare discussions. The MINTS stated that any nurse or physician without a tier badge must utilize professional interpreter services when treating patients with language barriers. The MINTS stated nurses utilizing interpreter services should document in the IFS.

During a concurrent interview and record review on 8/21/25 at 1:18 p.m., with RN 5 and MED 1, the document titled IFS dated 8/18/25 to 8/20/25 was reviewed, the IFS indicated that from 8/18/25 to 8/20/25 there was no documentation whether an interpreter was needed, interpreter type, the interpreter ' s name, the interpreter ' s session type, interpretation provided to, and interpretation location. RN 5 stated, interpreter services should be used when a non-English speaking patient is seen for medical screening. RN 5 stated when an interpreter is used, it should be documented. RN 5 stated the importance of having an interpreter present was to ensure clear communication with the patient. RN 5 stated "we need to be on the same page when sharing information". RN 5 stated, without proper interpretation, there was the significant risk of miscommunication, potentially leaving the patient unclear about their condition, treatment plan, or care instructions. MED 1 stated the physician ' s documentation contained no record of interpreter services being utilized for Pt 12 while in Provider at Triage (PAT) 1 on 8/16/25 at 8:47 a.m. MED 1 stated the interpreter usage should have been documented during each nursing shift, but the documentation was not completed. MED 1 stated the LNs failed to record the interpreter ' s names and Identification number in Pt 12 ' s medical records.

During a concurrent interview and record review on 8/21/25 at 1:25 p.m., with the MINTS, the document titled, "Flowsheet History" (FH) dated 7/22/25 to 8/21/25 indicated RN 10 documented on 8/17/25 at 7:30 a.m. "interpreter Type- Bilingual CMC Staff, Interpretation Method- In person/ direct Contact". The MINT stated when "In person/ direct Contact" is documented, it means the person that documented was the Interpreter. The document titled H & P dated 8/16/25 at 8:47 a.m. was reviewed, the H & P indicated Medical Director (MD) 1 saw Pt 12 on 8/16/25 at 8:47 a.m. The H & P indicated there was no documentation of interpreter service used during MD1 ' s visit. The MINTS stated RN 10 and MD 1 were not tiered staff and therefore were required to use interpreter services. The MINTS stated that all interpreter services usage must be documented in the IFS and the patients ' medical record as per the policy titled, "Interpreters/Translation: Non-English/Limited English Proficient & Deaf/Hearing Impaired ". The MINTS stated the importance of proper interpretation services is to ensure informed decision-making in patient care. The MINTS stated that failure to provide adequate interpretation could result in adverse patients ' outcomes.

During a concurrent interview and record review on 8/21/25 at 2:37 p.m., with the Director Critical Care Services (DCC) and the Manager of Intensive Care Unit (MICU), the document titled, EDTL was reviewed, the EDTL indicated Pt 12 was transferred to the Intensive Care Unit (ICU) on 8/19/25 at 12:25 p.m. The document titled IFS dated 8/19/25 to 8/21/25 was reviewed, the IFS indicated there was no documentation by the nurses that interpreter services were used in communication with Pt 12 or family members. The DCC stated Pt 12 was admitted to the Intensive Care Unit (ICU) on 8/19/25 at 12:25 p.m. The DCC stated Pt 12 was Spanish speaking and required Interpreter services to ensure comprehension of the plan of care. The DCC stated LNs are expected to utilize interpreter services when caring for patients with language barrier. The DCC stated the nursing documentation lacked any record of interpreter services usage. The DCC stated the LNs failed to document their use of interpreter services in the Pt 12 ' s medical record. The MICU stated Pt 12 was in the ICU for encephalopathy (any disorder affecting brain function, causing symptoms like confusion, personality changes, memory loss, and in severe cases, coma), sepsis, increasing oxygen (O2) requirements. The MICU stated the expectation was that LNs should communicate with patients in a manner they can understand and properly document all the interpreter services used. The MICU stated the importance of providing interpretation services was that patients had the right to receive medical information in their preferred language and to be fully informed about their care. The MICU stated that without proper interpretation services patients may experience adverse outcomes due to lack of understanding about their condition and treatments. The MICU stated communication barriers could potentially lead to a decline in patient status and overall condition.

During an interview on 8/25/25 at 1:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated, staff should validate the translator ' s status and level of training for language interpretation as per the policy. The CNO stated, otherwise, the staff should use the computer interpreter services that are contracted by the hospital.

During a review of the hospital policy and procedure (P&P) titled, "Interpreters/Translation: Non-English/Limited English Proficient & Deaf/Hearing Impaired ", dated 6/14/24, the P&P indicated, "PURPOSE: A. To define the communication system that is used for patients who have Limited English Proficiency (LEP) ... B. To provide guidelines for coordinating timely response in meeting the assessed special language needs of individual patients ... C. To comply with Americans with Disabilities (ADA), Title VI of the Civil Rights Act of 1964 and Health and Safety Code of California ... 1. Health and Safety Code of California requires licensed general acute care hospitals to provide language assistance services to patients with language or communication barriers ... Community Medical Centers (CMC) has contractual agreements that define expectations and response time, and those vendors are the only language contract services that must be used E .... Upon testing and training, such a staff member is assigned a one or two badge buddy, depending on their scope of competency in the given targeted language F. Language Service Line: Language services are available via phone 24 hours a day, 7 days a week ... G. Non-English or LEP: Those individuals whose native language is other than English and who cannot speak, read, write or understand the English language at a level that permits them to interact effectively with health care providers ... VI. DOCUMENTATION: B. Requesting staff members document in the patient's EHR if an interpreter or device is/ was used for the following 1. a) Name of the interpreter, including i. interpreter used (first and last name) ii. Interpreter agency, as appropriate iii. Time iv. Date ...2. If the requesting staff member is a tiered bilingual staff, can document in their notes or the interpreter flow sheet that they themselves interpreted.

A review of professional reference, "American Journal of Medicine- Interpreters in Health Care: A Concise Review for Clinicians", found at "https://pubmed.ncbi.nlm.nih.gov/31935351/", dated Jan 11 2020, the reference indicated, " ...Conclusion: It is our duty, both ethically and legally, to provide an environment where our patients can feel comfortable knowing they will be listened to and offered information in a language they can understand. The use of a well-trained health care interpreter is often the most important step in fulfilling this duty ..."

During a review of a professional reference titled, "Interpreter services and effect on healthcare - a systematic review of the impact of different types of interpreters on patient outcome." Found at "Journal of migration and health, 7, 100162. https://doi.org/10.1016/j.jmh.2023.100162", dated 24 Jan 2023, the reference indicated " ... Utilization of interpreters to facilitate communication between health care providers and non-native speaking patients is essential to provide the best possible quality of care .... Results were indicative of in-person professional interpreter resulting in highest satisfaction and communication, ... In-person Professional interpreter is the interpreter type resulting in greatest satisfaction and best communication outcome for the patients .... In conclusion, professional interpreter is the interpreter type resulting in greatest satisfaction and best communication for the patients, when compared to other types of interpretation or none, and should be used in the ER, in- and out-patient clinics or hospitals, when available ...."

During a review of a professional reference titled, "Safety first: The importance of interpreters & translated documents in preventing patient harm", found at "https://wmc.wa.gov/safety-first-importance-interpreters-translated-documents-preventing-patient-harm", dated October 7, 2020 the reference indicated, " ... When used effectively, interpreters and translated documents not only enable providers to communicate with their LEP [limited English proficiency] and NEP [non-English proficiency] patients, but also help promote patient safety by preventing medical errors and patient harm, which will minimize health disparities within this population ... open communication channels with their provider allows these patients to truly be in the center of their care ..."

Based on interview and record review, the hospital failed to promptly notify Patient (Pt) 1's family/Responsible Party (RP, a person designated by the patient who can make medical decisions on behalf of the patient) of his admission to the hospital on 5/25/25 at 2:53 a.m. and did not notify the family/RP until nearly three hours later after Pt 1 died.

This failure resulted in Pt 1's family and Responsible Party's inability to participate in medical decisions for Pt 1.

Findings:

During a review of Pt 1 ' s "Emergency Medical System (EMS) Run Sheet (RS, a document describing the assessment and treatment of a patient in route to the hospital)", dated 5/24/25, the RS indicated EMS was called to a Skilled Nursing Facility (SNF) where Pt 1 resided, due to Pt 1 experiencing abdomen pain, nausea and vomiting for 24 to 36 hours. The RS indicated Pt 1 was found to be hypotensive (low blood pressure) and two electrocardiograms (EKG, a test that records the heart ' s electrical activity) which each revealed a STEMI (ST-Segment Elevation Myocardial Infarction, a severe heart attack caused by a complete blockage of a heart artery, leading to a lack of oxygen and damage to the heart muscle). The RS indicated Pt 1 was transported to the hospital.

During a review of Pt 1 ' s "Emergency Department Timeline (EDTL)", dated 5/24/25 - 5/25/25, the EDTL indicated Pt 1 arrived in the ED by ambulance at 7:35 p.m. on 5/24/25. The EDTL indicated Pt 1 was treated for hypertension (high blood pressure) and sepsis (a life-threatening emergency that occurs when the immune system overreacts to an infection causing organ dysfunction and potentially death). The EDTL indicated Pt 1 continued to experience a high heart rate, low oxygen levels, and respiratory distress and was eventually intubated (a breathing tube inserted through the mouth and down into the windpipe for air to get through) at 11:29 p.m. The EDTL indicated Orders for Pt 1 to be admitted to the inpatient intensive care unit (ICU) on 5/25/25 at 2:53 a.m. The EDTL indicated Pt 1 had an arterial line (art line, a tube inserted into a large artery for fluids and medication administration and measuring arterial pressure) placed at 4:40 a.m. The EDTL indicated while nursing staff were attempting to get a reading from the art line, Pt 1 ' s telemetry monitor (recording of patient ' s heart rhythm) reading was noted to be asystole (no heart rate) and a code blue (cardiac and respiratory resuscitation) was started at 4:51 a.m.

During a review of Pt 1 ' s "Code Timeline (CTL)", dated 5/25/25, the CTL indicated despite resuscitation efforts Pt 1 died at 5:09 a.m.

During an interview on 8/21/25 at 2:18 p.m. with Pt 1 ' s daughter (Complainant, CO 1), CO 1 stated her husband was Pt 1 ' s RP. CO 1 stated she and RP 1 did not know Pt 1 was at the hospital. CO 1 stated they first received a call from the hospital from a social worker on 5/25/25 at 5:45 a.m., who asked if RP 1 was coming to the hospital. The second call was from a doctor on 5/25/25 at 5:55 a.m. to tell RP 1 Pt 1 had died.

During an interview on 8/25/25 at 1:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated a patient ' s family member or Responsible Party should be notified of a patient ' s admission as soon as possible so they are aware and can make decisions regarding the care of the patient.

During a review of the hospital ' s policy & procedure (P&P) titled, "Patient ' s rights and Responsibilities", dated 3/14/25, the P&P indicated, " ... PATIENT RIGHTS ... A. Patients are applicable to all [name of hospital ' s parent company] patients ... the hospital shall provide processes to support the following patient rights ... 3. To have a family member (or representative of choice) ... notified promptly of admission to the hospital as soon as possible ...8. To be informed and, when appropriate, for their families to be informed about the outcomes of care, including unanticipated outcomes ... ...".

Based on observation, interview, and record review, the hospital failed to securely store medications, when one of two sampled anesthesia (temporary loss of feeling or awareness to prevent pain) medication cabinets containing inhalation (breathe in) anesthetics (medicine to cause deep sleep) were left unlocked in OR 2 on Campus 2. This violated the hospital's "Medications - Orders, Administration, Storage, Documentation" policy.

This failure had the potential for unauthorized staff to access anesthetic medications with the possibility of diversion (when a medication is taken for use by someone other than whom it is prescribed or for a reason other than what it is prescribed).

Findings:

During a concurrent observation and interview on 8/19/25 at 2 p.m., with Registered Nurse (RN) 6, and Nurse Manager (NM) 2 in OR 2, a cabinet labeled "Inhalation anesthetic agents stored inside" was unlocked. RN 6 explained that the medications were gases used in the anesthesia machine to put patients to sleep during surgical procedures. The cabinet contained six unopened containers of anesthetic agents: two 250 milliliter (mL-a unit of volume measurement) metal bottles of sevoflurane (an inhaled, medication used to start and maintain deep sleep for surgical procedures), two 100 mL dark brown glass bottles of isoflurane (another inhaled medicine used to start and maintain deep sleep for surgical procedures), and two 240 mL metal bottles of desflurane (another inhaled medication to start and maintain sleep for surgical procedures) RN 6 stated that the cabinets were "monitored" but not locked (no nursing staff were in the OR, or in the hallway around the OR prior to our entry monitoring the room). RN 6 added that anesthesiologists (physicians who specialize in administering anesthesia during medical procedures) were often in a "hurry", so they left the cabinet open in the morning, and they relied on the closing technologists to lock it overnight. When asked whether the anesthetic agents were always emergent-justifying the anesthesiologist's need to hurry and the cabinet remaining unlocked between cases-RN 6 responded, no. RN 6 clarified that anesthesia technologists were responsible for locking and unlocking the cabinets, but a key was also available in the automated medication dispensing system, allowing nursing staff to access it. Nurse Manager (NM) 2 stated that staff should lock the cabinet when no surgical cases were in progress. NM 2 emphasized that locking the cabinet was important to prevent unauthorized access, as only anesthesia staff should handle these medications.

During an interview on 8/25/25 at 1:36 p.m. with the Chief Nursing Officer (CNO), the CNO stated medications used for anesthesia should be in a locked area. The CNO stated when medications were not in a locked area there was a chance for someone other than the anesthesiologist to get ahold of the medication and have a bad outcome (harm).

During a review of the hospital P&P tiled, "Medications - Orders, Administration, Storage, Documentation," dated 6/30/25, indicated, " ...Medication Storage ...Medication storage areas are to be locked when not in use. ...Only authorized personnel will have access to medication storage areas. ...Authorized personnel include i. Registered Nurse ii. Licensed Vocational Nurse iii. Pharmacy personnel iv. Providers v. Respiratory Care Practitioner ...And other personnel who are authorized to administer medications ...Medications will be securely stored at all times and at the appropriate temperature ..."

During a review of the professional reference titled, "Statement on Security of Medications in the Operating Room," dated 10/18/23, the professional reference indicated, " ...A secure environment of care is necessary for medication safety. Medication safety includes the security of oral, sublingual [under tongue], parenteral [typically by injection (needle) or infusion (plastic line into vein)], and inhaled pharmaceutical agents used for elective and emergency patient care. A secure physical area ensures the integrity of anesthesia machines as well as other equipment and materials. Security of medications, while maintaining rapid accessibility, in a secure anesthetizing location is essential for patient safety. ...CMS has provided specific guidance on security in the OR environment in the Federal Register on November 27, 2006, Vol. 71, No. 227. The document states the following: "An area in which staff are actively providing patient care or preparing to receive patients, that is, setting up for procedures before the arrival of a patient, would generally be considered a ''secure area.'' For example, the operating room suite would be considered secure when the suite is staffed and staff are actively providing patient care. When the entire suite is not operational or otherwise not in use, for example, weekends, holidays, and after hours, the suite would not be considered secure. When the suite is closed or otherwise not in use, we would expect all drugs and biologicals to be locked ..."