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Based on review of medical records and other pertinent documentation, as well as interviews with staff, it was determined the hospital failed to consistently provide interpreter services for Patient #1 (P1), Patient #4 (P4), and Patient #9 (P9) who were all LEP (Limited English Proficiency) patients. This was evident in 3 out of 4 records reviewed for the use of translator services.

During an interview with nursing staff on June 3, 2020 at approximately 11:00 am, the statement was made by staff members that sometimes nurses translated for patients. When asked if these nurses were certified medical translators, the response was 'no'.

P1 was a 65+ year old patient who was transferred to the facility from another hospital due to an upgrade in their health status. The patient had previously been an inpatient in the Intensive Care Unit (ICU) for almost a month.

On admission, it was documented that the patient presented with "mild difficulty breathing". It was also documented that P1's primary language was Spanish; however, the physician documented that the patient, "completes 6-7 word sentences". No documentation was found to support that an interpreter was used for the initial intake and assessment of the patient's current condition and needs.

During this admission, P1 had two documented changes in condition. One nursing note stated, "Patient is Spanish speaking. Writer able to communicate effectively without the use of an interpreter for assessment and follow-up from previous change in condition". No notes were found to support that an interpreter was used to obtain pertinent information from the patient or to explain the treatment plan to address those changes.

Discharge instructions noted the use of an interpreter for P1; however, discharge took place after surveyors reviewed medical records and discussed the lack of interpreter use.

P4 was a 45+ year old patient who was transferred to the facility from another hospital for additional support prior to discharge home. The patient was documented as having continued decreases in their oxygen after walking. The physician ordered close monitoring of oxygen saturation and physical therapy. Nursing documented under "psychosocial barriers - Burmese is primary language" and under "Education -Considerations: language barrier".

The initial History and Physical (H&P) examination completed by the physician, which included pertinent past and current medical information regarding the patient's condition and symptoms, did not document the use of an interpreter. The physician's note stated, "Communicates well without interpreter in simple language and simple answers. Would benefit from interpreter for discharge plans to ensure understanding of all plans and having all questions answered".

Discharge documentation was reviewed and the physician note stated, "Primary language is Burmese. Communicates well without interpreter in simple language and simple answers". No documentation was found to support that the physician, nursing or Social Work staff used an interpreter to explain the plan or discharge instructions to the patient.

P9 was a 50+ year old patient who was admitted related to an inability to self-isolate within the community. Per medical record review, P1's History and Physical (H&P) stated that the patient was Spanish-speaking; however, no documentation was found to support that interpreter services were offered to the patient or utilized by the patient.

On the third day of admission, nursing staff documented that a "T2 [a certified nursing assistant], fluent in Spanish assisted with transaction of assessments." There was lack of evidence noted in the medical record of the patient's preferred language and /or understanding of the English language. Further record review determined that both medical and nursing staff failed to utilize and/ or document the use of interpreter services for this Spanish-speaking patient.

The hospital's failure to communicate with Patients #1, #4, and #9 in a language they understood precluded these patients from actively participating in development and implementation of their treatment plans. Furthermore, it could could not be determined whether these patients understood their discharge instructions and follow-up care needs.

Based on review of pertinent documents and interviews with nursing staff and facility's leadership, it was determined that facility lacked a process for verification of nursing phlebotomy skills and competency. In the absence of a verification process of nursing phlebotomy skills and competency, it was unclear if the hospital had an ability to adequately meet patient needs for laboratory services in this specialized clinical setting.

It should be noted that during a state licensure visit by OHCQ in April 2020, the facility had a plan that the laboratory services would be performed by a vendor or contracted service, which would come on site to obtain patient samples.

Nursing staff in the clinical area and facility's leadership were interviewed on June 3 and June 4, 2020 about the current process of obtaining patient labs within the "Hot Zone". The interviews determined that the above-described process had been changed to have the existing nursing staff draw labs, as ordered. The obtained samples were then sent with a courier to an offsite lab contracted by BCC ACS.

Surveyors asked the facility's leadership the following question, "What nursing personnel, by title, were allowed to draw blood for labs?" The response was, "Tier I - Registered Nurses and Tier II - nursing technicians, are allowed to perform blood draws based on the staff's verbalization of ability and past work environment." It was further stated as an example, "If a Tier I or Tier II previously worked in an emergency department or similar acute area, and stated that they could draw patient labs, then they were allowed to draw labs". The facility did not have any established process to assess and validate staff's ability to perform this skill. Staff were not required to demonstrate skills or present certification of phlebotomy skills for verification at BCC ACS.

In addition, review of pertinent documents determined that there were delays in placing lab orders, retrieving and processing of samples. The delays were attributed to the lack of nursing staff on each shift who were trained and proficient in the use of the computer system that ordered and processed labs.

In summary, the hospital failed to have a process that tested and validated the nursing staff's ability to competently perform phlebotomy and other services related to the collection and processing of lab specimens which could potentially affect the ability of the hospital to meet the laboratory services needs of its patient population.

Based on review of refrigerator and freezer temperature control logs for May and June 2020, it was determined that the facility failed to consistently monitor for required temperature controls of the refrigeration units in its food preparation area as evidenced by multiple missing entries on the May 2020 temperature control logs for various refrigerators and freezers reviewed by surveyors while onsite. It shouild be noted that the temperatures were within required ranges when the survey was performed.