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Tag No.: A0083
Based on a review of the clinical record, the governing body failed to be responsible for all services furnished in the hospital, whether furnished directly or under contract.
Findings were:
During a review of 10 clinical records, 1 of 10 records (patient #1) gave no indication that interpreter services were utilized in the care of the patient in order to provide care for her in her preferred language of Spanish.
Review of facility policy entitled, "Language Barrier, Hearing Impaired, Speech Impaired, Visually Impaired - Language Access Services (LAS) for Limited English Proficiency (LEP) Patients" effective date: 05/31/13, revealed, the following: "Patients/surrogate decision-makers of MMH shall have services provided to them in their primary language via interpreter services, visual or tactile aides provided to them during the delivery of all significant healthcare services. Language access services shall be available within a reasonable time, at no cost to patients. Effective communication is important in every area of hospital communication, but MMH prioritizes the most careful attention to effective communication in the provision of medical, nursing and ancillary services, where patient safety, medical error, and ability to understand treatment options are affected."
The Admission Health History for patient #1 dated 8/26/13 at 14:52 stated, "Language/Communication Barrier: Yes, Preferred Language: Spanish."
The above was confirmed in an interview with the Director of Quality and the QMS Specialist during the afternoon of 12-11-13 in the Quality Director's Office.