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Based on review of the Emergency Department Record and staff interview, the Hospital failed to provide an American Sign Language Interpreter on 09/13/10 for Patient #1's Spouse who was deaf.

Findings include:

Background information:

Review of the medical record indicated that Patient #1 was transported to the ED with advanced life support following a motorcycle accident. Cardiopulmonary resuscitation (CPR) was initiated at the scene and continued in the ED without success. Patient #1 expired. Nursing Supervisor #1 was interviewed in person on 02/13/12 from 11:30 A.M. to 11:50 A.M. Nursing Supervisor #1 did not provide an interpreter for Patient #1's Spouse when requested.

Review of the Emergency Medical Service (EMS) Report and the Emergency Department (ED) Record for Patient #1 dated 09/13/10 indicated Patient #1 was found, face down and unresponsive. Patient #1 was without spontaneous respirations and a pulse. Advanced life support was initiated and continued during transport to the ED. Cardiopulmonary Resuscitation efforts continued in the ED without success. Patient #1 died.

1) Nursing Supervisor #1 was interviewed in person on 02/13/12 from 11:30 A.M. to 11:50 A.M. Nursing Supervisor #1 said that she went to the ED to support the family. Nursing Supervisor #1 said Patient #1's Spouse requested to have an interpreter. Nursing Supervisor #1 said Patient #1's Spouse did not want to use the telephone for the deaf. Nursing Supervisor #1 said that she called the interpreter service, but was informed no one was available. Nursing Supervisor #1 did not request the interpreter services on line, according to the Hospital Policy for Interpreter Services, nor did she access the American Sign Language live video interpreter for the Spouse. Nursing Supervisor #1 said that she thought it would be more compassionate to speak to the Spouse herself because the Spouse could read lips.
The Nursing Supervisor did not effectively communicate with Patient #1's Spouse. The Nursing Supervisor denied Patient #1's Spouse a request to have an interpreter during a critical need. The Nursing Supervisor denied Patient #1's Spouse the right and opportunity to understand the severity of Patient #1's injuries and death.

Based on review of documentation, interviews and review of the Complaint file, the Hospital failed to provide the Complainant with a written notice of the results of the investigation which addressed the essence of the complaint.

Findings include:

The Patient Advocate was interviewed in person on 02/13/12 from 11:52 P.M. to 12:15 P.M. The Patient Advocate said that a complaint was filed with the Hospital on 11/16/11 about the interpreter services not being provided to Patient #1. However, review of the ED record indicated that Patient #1 was unresponsive and continuous resuscitation was being provided. Review of the Complaint file indicated that the complaint letter was filed through a telephone service for the deaf in an email format. The message was unclear in that the Spouse/Complainant was "looking for a report/document on a deaf patient." Clarification was sought and the response was: "for the interpreter that was used on 9/13/10." Further emails addressed a plan to meet with the Spouse/Complainant with a Sign Language Interpreter present, but the meeting was declined. The Spouse responded in an email indicating that she did not want to have a meeting, "all I'm asking is did the ER requested an American Sign interpreter the date of September 13, 2010."

Review of the complaint file indicated that the Patient Advocate was persistent in attempting to contact the Spouse. The Patient Advocate sent seven e-mails from 11/16/11 to 11/22/11 to the Spouse. Despite many efforts made to have contact with the Spouse, meetings were declined. The essence of the complaint was never clarified, an assumption was made that the complaint was about Patient #1 not being provided with an interpreter. Based on Patient #1's unresponsive condition and ultimate death, Patient #1 was not able to communicate.

Review of the Hospital's Complaint Response Letter dated 12/09/11 indicated an interpreter was not provided to Patient #1 because of Patient #1's medical condition and inability to communicate. The letter never answered the Spouses question about the request for an American Sign Language Interpreter. Despite ongoing challenges in communicating with the Spouse, the essence of the complaint, the Spouse never being provided with an interpreter as requested, was never addressed. The investigation also did not include the fact that Nursing Supervisor #1 did not follow hospital procedure in providing the Spouse with an American Sign Language Interpreter when requested. According to interview with the Surveyor, Nursing Supervisor #1 assumed that the Spouse could read her lips and understand the circumstances that lead to Patient #1's death.