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Based on a review of the medical record, staff interviews, and facility policies and procedures, it was determined that the facility failed to protect, promote, and allow the patient to exercise the patient's rights when one patient (P#1) sampled out of 20 patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18, P#19, and P#20) failed to receive interpreter services when seeking care at the facility's emergency department (ED) as evident by lack of documentation in the patient's electronic medical record.

Findings Included:

Continued review of the medical revealed that P#1 denied any past medical history and had a primary language of Spanish.

Continued review of the medical record revealed no documentation by staff of interpreter services utilized while P#1 was in the facility.

A review of the facility's policy titled "Patient Rights and Responsibilities" no number, last reviewed 8/9/24, revealed the following:

Patient Rights (CMS 482.13)

3. The patient had the right to participate in the development and implementation of his or her care.
4. The patient or his or her representative (as allowed under State law) had the right to make informed decisions regarding his or her care. The patient's rights included being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment, or services deemed medically unnecessary or inappropriate.

A review of the facility's policy titled, "Interpreter Services: Patients with Special Needs: Hearing Impaired, Sign Language, Visually Impaired, and Language Interpretation", last revised 12/15/21, revealed that the purpose of the policy was to detail that the facility effectively communicates with patients when providing care, treatment, and services.

Continued review revealed that the facility recognizes the special needs and concerns of individuals who are hearing impaired or of linguistic and cultural minority groups who are limited English proficient (LEP). The facility will provide special communication devices along with qualified interpreters and translation services to patients in accordance with applicable State and Federal Laws.

Continued review revealed, Procedures:
2. Notification of Rights to LEP patients. Informs LEP patient that a qualified interpreter at no cost to them for discussion of information necessary for healthcare or financial decisions.
4. Use of Interpreters
3.1. Interpreters shall be used in any situation where clear and effective communication is necessary.
3.2. All interpreter services provided should be documented in the medical record.

A phone interview with Registered Nurse (RN) EE was completed on 7/24 /24 at 10:36 a.m. from the facility's main conference room. RN EE said that in triage, if the patient does not speak English, the RN can call a translation line for the patient. RN EE said that the translation call is not required to be documented in the patient's record.

During a telephone interview on 7/24/24 at 1:37 p.m. in the conference room, Registered Nurse (RN) LL said that she was an emergency department (ED) RN for two years and employed by the facility for one year. RN LL said that she works at the main ED station and triage. RN LL said that if a patient does not speak proficient English, then staff can use interpreter services via a telephone. RN LL said that staff do not document the use of interpreter services.

A phone interview was conducted from the main conference room on 7/24/24 at 2:35 p.m. with the Patient Account Registrar (PAR) HH. PAR HH said that if the patient does not speak English, there is a phone translation service that they can use. PAR HH said that sometimes, patients have a family member who speaks English, or they may use a translation program on their phone.
PAR HH said that the ED registration and consent forms are available in English and Spanish.

During an interview on 7/24/24 at 2:41 p.m. in the conference room, the Emergency Department (ED) Director of Nursing Services (EDNS) CC said that staff should document in the patient's chart when and if they utilize interpreter services.

During an interview on 7/24/24 at 3:01 p.m. in the conference room, the Director of Patient Access (DPA) NN said that when a patient presents to the emergency department (ED), they are greeted by a registrar who takes the patient's information. DPA NN said that this information is filled out by the patient on a form that is available in both English and Spanish and then scanned in for an off-site team to complete registration in India. DPA NN said that for patients who do not speak English as a primary language, staff are able to use interpreter services and it should be documented in the patient's medical record. DPA NN also that if staff speak the same language, then they can translate because the work that registrar performs is not clinical.

Based on review of policy and procedures, incident logs, and interviews with staff it was determined that facility staff failed to adhere to facility policies for nine (P#1, P#2, P#5, P#9, P#10, P#14, P#16, P#18, and P#20) of 20 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18, P#19, and P#20) when it was determined that a patient incident report was not submitted when patients left the emergency deparment prior to receiving a medical screening examination (MSE) or against medical advice (AMA).

Findings included:

A review of the facility's policy titled, "EMTALA-Compliance with the Emergency Medical Treatment and Active Labor Act", no
number, last reviewed 1/1/24, revealed that any individual who "comes to the hospital emergency department" requesting examination or treatment would be provided with an appropriate medical screening exam (MSE).
Procedures:
2. Left Without Being Seen (LWBS)- If an individual left the hospital before being seen for the MSE, the hospital was not in violation of
EMTALA. The hospital needed to document the circumstance of the individual leaving as well as retain all notes pertaining to the hospital visit. In addition, an incident report should be filled out using the appropriate system.
3. Against Medical Advice (AMA)- If an individual decided to leave the hospital AMA, the hospital was not in violation of EMTALA. The hospital needed to document the circumstances of the individual leaving as well as retain all notes pertaining to documenting the circumstances of the individual leaving as well as retain all notes to that hospital visit. In addition, an incident report should be filled out using the appropriate system.

A review of facility ' s incident log dated 2/13/2024 through 7/21/2024, failed to reveal an incident related to leaving the ED for P#1, P#2, P#5, P#9, P#10, P#14, P#16, P#18, and P#20.

During a telephone interview on 7/24/24 at 1:37 p.m. in the conference room, Registered Nurse (RN) LL said that she was an emergency department (ED) RN for two years and employed by the facility for one year. RN LL said that if a patient left without being seen (LWBS) then staff are supposed to call the patient's phone and inform the charge nurse. RN LL said that staff are supposed to document three attempted calls for patients who LWBS in the electronic medical record. RN LL said that an incident report did not have to be filed.