HospitalInspections.org

Based on record review and interview, the hospital failed to ensure each patient was informed of his/her patient care rights in a manner that he/she could understand. This deficient practice was evidenced by failing to ensure the services of a translator or interpreter were available to facilitate communication between the patient and hospital staff for 3 (#1, #2, #3) of 3 non-English speaking patients sampled.
Findings:

Review of the hospital policy titled Patient's Rights and Responsibilities effective 01/2022 revealed, in part: Procedure: B. For patients with language barriers or those that are unable to read, the contents of the statement should be interpreted and/or explained to the extent possible in a language the patient can understand.

Review of the hospital Patient Bill of Rights and Responsibilities revealed, in part:
You have the right to ...12. Have access to interpreter services at no cost to you or your companion when you do not speak or understand the language.

Review of the hospital policy titled Communication, Non-English Speaking effective 05/2017 revealed, in part:
Policy: If language or communication barriers exist between staff and patients, arrangements shall be made for interpreters or for the use of other mechanisms to ensure adequate communication between patients.
Procedure:
1. When confronted with a situation which requires an interpreter, the Social Worker has the phone numbers of the contracted agencies who can provide assistance with interpretation.
2. The Social Worker will make contact with the appropriate interpreter service that can meet the need of the patient.
3. The Social Worker will arrange for the interpreter to come into the hospital to provide services for the patient.
4. The Social Worker will communicate to the patient/significant other that interpretation services will be provided.

Review of Patient #1, Patient #2, and Patient #3's medical records revealed all three patients non-English speaking patients. Further reviewed revealed documented evidence of communication issues between patients and staff.

In an interview on 04/22/2024 at 11:34 a.m., S4LPN confirmed Patient #1 and Patient #2 were non-English speaking patients. S4LPN confirmed hospital staff tried to communicate with Patient #1 and Patient #2 with a communication board and cell phone translate app without success. S4LPN indicated the communication barrier made it difficult to provide routine nursing care for Patient #1 and Patient #2. S4LPN indicated the hospital did not have translator or interpreter services to provide assistance with communication between non-English speaking patients and hospital staff.

In an interview on 04/22/2024 at 11:47 a.m., S3RN confirmed Patient #1 did not speak or understand English. S3RN indicated Patient #1 would often get agitated and frustrated when trying to communicate with the patient using a communication board and cell phone translate app. S3RN indicated hospital staff had to call Patient #1's son to come to the hospital to help with communication between Patient #1 and hospital staff. S3RN indicated the hospital did not have translator or interpreter services to provide assistance with communication between non-English speaking patients and hospital staff.

In an interview on 04/22/2024 at 12:39 p.m., S2Nurse Manager confirmed Patient #1, Patient #2, and Patient #3 were non-English speaking patients. S2Nurse Manager indicated the communication barrier between Patient #1, Patient #2, and Patient #3 made it difficult for staff to provide routine nursing care. S2Nurse Manager indicated the hospital did not have translator or interpreter services to provide assistance with communication between non-English speaking patients and hospital staff.

In an interview on 04/22/2024 at 1:16 p.m., S5Case Manager indicated she was not aware of hospital contracted agencies or other arrangements to provide assistance with interpretation between non-English speaking patients and hospital staff.

In an interview on 04/24/2024 at 11:09 a.m., S1Administrator indicated the hospital did have interpreter services. S1Administrator indicated hospital staff not aware of this service and needed education on this subject.

Based on observation, record review, and interview, the hospital failed to protect the patient's right to personal privacy. This deficient practice was evidenced by allowing a patient's (#1) family member to attend therapy sessions with other hospital patients present in the therapy room without obtaining his/her prior consent.
Findings:

Observation on 04/22/2024 at 1:19 p.m. revealed a sign posted on the wall outside of the hospital therapy room in all capitalized letters that read: Stop. No visitors or family members allowed beyond this point!

Review of the hospital policy titled Patient Visitation effective 01/2018 revealed, in part:
Procedure: D. Visitor access is limited to public areas of the hospital.

In an interview on 04/22/2024 at 1:22 p.m., S6PT confirmed no visitors or family members were allowed in the hospital therapy room.

In an interview on 04/22/2024 at 1:24 p.m., S7OT confirmed no visitors or family members were allowed in the hospital therapy room. S7OT confirmed Patient #1 did not speak English and Patient #1's son needed to be present during therapy sessions for him to communicate with the patient. S7OT confirmed other hospital patients received therapy in the presence of Patient #1's son.

In an interview on 04/22/2024 at 12:39 p.m., S2Nurse Manager confirmed Patient #1's son was present during therapy sessions while other patients received therapy. S2Nurse Manager confirmed only hospital patients should be in the therapy room during sessions to protect the privacy of other patients. S2Nurse Manager indicated prior consent or approval was not obtained from the other patients that were present when Patient #1's son was in the therapy room.