Based on record review and interview the facility failed to establish, evaluate, and update policies and procedures for emergency services for triaging (the evaluation and classification of patients for the purposes of treatment) and screening patients. This failure has the potential to cause harm to patients by not establishing a process to triage and screen patients that enter the emergency room at the facility. The findings are: A. Record review the facility's policies and procedures the facility does not have a policy or a procedure on triaging patient that enter the emergency room of the facility. The facility uses the Admission of Patients to the ED policy as the policy to triage patients. The Admission of Patients to the ED policy only states that the triage nurse is to use the Emergenccy Severity Index (ESI - five-level emergency department triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs) scale. B. On 1/2/19 at 3:00 pm during an interview with the Charge Nurse in the emergency room (S#10) that triaged patient P#1 on 12/24/18 she confirmed that there is not a written policy or procedure on triaging patients when patients come into the emergency room . C. On 1/2/19 at 3:00 pm during an interview with S#10 (triaged P#1) it was confirmed that on 12/24/18 on the P#1's initial visit, during the triage process P#1 and his father was not asked about P#1's vaccination history or past medical history. S#10 stated that this is done by the nurse that assumes care of the patient. D. On 1/3/19 at 3:00 pm during an interview with S#14 that assumed care of P#1 after triage it was confirmed that she did not ask P#1's father about vaccination history or status and past medical history. S#14 stated that questions about vaccination history and status are done during triage and that the providers are the ones that ask about past medical history of the patient during their initial exam. E. On 1/3/19 at 10:00 am during an interview with S#2 (the provider for P#1) confirmed that he does not recall if he asked the father of P#1 about vaccination history or status and past medical history of P#1 during his initial exam of P#1.

Based on record review and interview the facility failed to ensure there were adequate nursing personnel trained and qualified in emergency care to meet the needs anticipated by the facility for 1 (P#1) of 20 (P#1 through P#20) patients . This deficient practice has the potential to affect the care, treatment and outcome who presents to the Emergency Department (ED) for treatment. The findings are: A. On 1/2/19 at 2:13 pm during interview S#10 confirmed Border Patrol Agent did all translation for P#1 during his treatment. B. On 1/2/19 at 2:22 pm during interview S#10 confirmed there weren't any policies for translation services. C. On 1/3/19 at 9:17 am during interview S#2 confirmed never gone through certification process for translation and stated "I've never seen a written policy that I am aware of at this point." D. On 1/3/19 at 12:00 pm during interview S#8 confirmed there is a number to call on the hospital's web page. S#8 also stated that the ED staff on call spoke Spanish and didn't see the need to call translation services. S#8 also confirmed that S#8 does not document what language a patient speaks on the medical record. E. On 01/03/19 at 3:01 pm during interview S#14 confirmed that he/she did not know of translation services. S#14 further stated "I don't recall if the discharge instructions were in English or Spanish, there is no way for me to change it." S#14 could not confirm if the father of the patient understood the information provided to him. F. On 01/13/19 at 3:15 pm during interview S#15 stated "the two people who speak Spanish were in the room during the code (patient was not breathing on his own and did not have a pulse) S#15 confirmed "I know a translation policy exists, I know where to find it, a binder somewhere at the desk, but don't recall being given a policy." G. On 01/11/19 at 11:50 am during interview, S#17 stated that S#17 completed the interpreter services education module the other day, knows where and how to access but has not used the interpreter services before. H. Record review of "Patient Rights" Policy, May 29, 2018, states that "The Patient Handbook and Patient Rights flyer will inform the patient of the following patient rights: COMMUNICATION - Each Patient has the right to access to people outside the hospital by means of visitors and by verbal and written communication. When the patient does not speak or understand the predominant language of the community, communication will be made through an interpreter". J. Record review of "Hospital Certification/Consent Form, April, 2018 for P#1 for both ED visits by P#1 on 12/24/18 were in English, not in Spanish (native language spoken by P#1 and P#1's father). The hospital has a "Hospital Certification/Consent Form" in Spanish readily available.

Based on observation, record review and interview, the facility failed to conspicuously post in the treatment area, a sign in Spanish specifying the EMTALA (Emergency Medical Treatment and Labor Act) rights of individuals under Section 1867 of the Social Security Act (SSA) in the emergency department (ED). This deficient practice has the potential to have any person who presents to the ED from fully knowing and understanding the EMTALA rights under the SSA and to know if the hospital participates in the Medicaid program, if their primary language is one other than English. The findings are: A. On 01/02/19 at 1:45 pm during tour of the ED, Patient Rights signs posted near the Triage/ER Intake Window in the ED waiting room was in three languages: English, German and Spanish. Patient Rights signs posted in treatment areas, hallways and other patient-accessible areas within the ED were in English and German only. B. Record review of "Patient Rights" Policy, May 29, 2018, states that "The Patient Handbook and Patient Rights flyer will inform the patient of the following patient rights: COMMUNICATION - Each Patient has the right to access to people outside the hospital by means of visitors and by verbal and written communication. When the patient does not speak or understand the predominant language of the community, communication will be made through an interpreter". C. Record Review of "EMTALA" Policy, April 24, 2018, states that "7. Signage: (facility name) will conspicuously post signs in English, Spanish and German specifying: The rights of patients under EMTALA with respect to screening and stabilization for emergency medical conditions and patients in active labor; and That (facility name) participates in the Medicaid program". D. On 01/03/2019 at 3:30 pm, S#6 confirmed there was a Spanish EMTALA sign missing from the treatment area.

Based on record review and interview, the facility failed to provide stabilizing treatment and/or follow up care to prevent relapse or worsening of the medical condition upon discharge from the ER (emergency room - a department of a hospital that provides immediate treatment for acute illnesses and trauma). This failed practice has the likelihood to cause harm to patients that are discharged from the ER. Findings: A. Record review of P #1's chart revealed, P #1 was brought to the ER on 12/24/18 at about 10:25am, developed a fever of 103 degrees Fahrenheit (a scale of temperature in standard conditions) at about 1:00 pm. S #14 (P #1's primary nurse) notified S #2 (the provider caring for P# 1). S #2 ordered acetaminophen (used to reduce fever). S #14 administered the acetaminophen to P #1 at 1:20 pm. S #14 documented that P #1's fever came down to 100 degrees Fahrenheit at 1:50 pm. S #2 did not reassess P #1 for signs and/or symptoms that could cause P#1 to relapse after discharge. P #1 was discharge at 2:00 pm with a prescription for a antibiotic (a medicine that inhibits the growth of or destroys microorganisms). P #1's medical record revealed that P#1 was positive for Influenza B (a highly conttagious viral infection of the respiratory passages) before discharge and was not given a prescription for an antiviral medication (a medication that kills a virus or suppresses its ability to replicate). B. On 1/3/19, at 9:17 am, during an interview with S # 2 it was confirmed that S # 2 did not reassess P #1 after his initial assessment of P #1. S#2 stated that the examination performed was "non-focal, everything looked okay, non-toxic, he was talking and sitting, and it sounded to me like an upper respiratory problem. I ordered a flu culture and those test results for the flu were positive. I was notified by the nurse upon discharge that he had a fever spike, so Tylenol was given. " S#2 informed the surveyors that P#1 was discharged with an antibiotic (amoxicillin). S#2 stated no antiviral medication was given or prescribed for P#1. C. Record review of P #1's chart, the discharge instructions for P #1's was printed in English. P #1 and his father only communicate in Spanish. D. On 1/3//19 at 3:00 pm, S# 14 confirmed that she did not recall if she gave P #1 and his father the printed discharge instructions in Spanish.