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Based on record review and interview, the facility failed to have a registered nurse to evaluate the nursing care for 1 of 1 (Patient #1) patients in that the nurse did not call the language line to help evaluate a Spanish speaking patient after a fall.

Findings included:

Patient #1's History and Physical dated 11/28/18 at 1220 reflected that Patient #1 was Spanish speaking only. On 12/12/18 at around 1130 Patient #1 sustained a fall while in his room. The nurses note dated 12/12/18 at 1458 reflected the patient had no injury. There was no documentation of the use of the language line in the medical record for 12/12/18.

During a record review on 05/15/19 ending at 1235 Personnel #1 stated the hospital did have some Spanish speaking employees, but they were not used as interpreters because they were not certified as interpreters. Personnel #1 stated the language is used for all interpretations. Personnel #1 verified there was no documentation that the language line was used.

The Policy titled Interpreter Services dated 09/06 and revised 01/08 reflected..." This policy provides hospital personnel with a means to assist patients, families, visitors, and physician to affirm the basic rights of human beings to heard and understood...E...The choice of the patient and presence of an interpreter will be documented..."