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Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure all patients are provided information concerning patient rights, in a language that the patient understands.

Findings include:

Reference; Facility Policy, Title:Patient Rights,page 2 of 6, under Communication and Information states, "To receive as soon as possible, the services of a translator or interpreter or listening device if you need one to help you communicate with the hospital's health care personnel."

1. Documentation in Medical Record #7 on the face sheet states the patient's language is, "Spanish."

2. Documentation in Medical Record #7 on the ED Triage Note states the patient's language is, "Spanish."

3. Medical Record #7 contained general consent forms in English

4. Medical Record #7 contained discharge instructions in English.

5. There was no documentation in Medical Record #7 stating the patient spoke English, or was provided a translator or interpreter services.

6. The above was confirmed by Staff #1.

C# NJ 84617

Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure all medical records are accurately written and promptly completed.

Findings include:

Reference; Facility Policy, Nursing Documentation states, "To describe the process used to provide an ongoing record of information regarding nursing care, patients response to therapy, outcome of therapy/care provided, and patient progress ... 5. All nursing documentation must be completed by the end of the assigned shift ... 9. All notations made must be ... descriptive... ."

1. Upon interview with Staff #8, Staff #9 had attempted unsuccessfully to insert a Foley catheter as ordered by the physician for Patient #1.

2. There was no evidence in Medical Record #1, that Staff #9 notified the ordering physician that she/he was unable to insert the Foley catheter, as per policy above.

3. Upon interview with Staff #8, she/he stated that a male nurse did a second attempt at a Foley catheter insertion.

4. There was no evidence of the first and second Foley insertion attempts documented in Medical Record #1.

a. Staff #8 confirmed that the attempts at Foley insertion by the nurses was not documented in Medical Record #1 as per facility policy.

4. The above was confirmed by Staff #1.