ST MARY MEDICAL CENTER

Report ID: H5VT11.01, California Department of Public Health

Reported Entity: ST MARY MEDICAL CENTER

Issue:

Based on interview, and record review, the facility failed to provide aftercare discharge instructions in Spanish for Patient A, who was Spanish speaking only. This had the potential to result in Patient A not following up with the outpatient surgeon because the instructions were provided in English, and not in ttttttterms that the patietn could understand.Findings:On April 1, 2014 at 2:40 PM, a visit was made to the facility to investigate an entity reported incident of a breach of Patient A's protected health information (PHI).During an interview conducted with the Director of Accreditation on April 1, 2014 at 2:43 PM, she said, "Patient A had been in the emergency room on February 6, 2014, for complaint of abdominal pain. Patient A was to be discharged and given copies of her laboratory and radiology results to take to the outpatient surgery department. In addition, the Patient A received written instructions which included the names of the medications to be taken."A review of the Emergency Room physician's discharge plan dated February 6, 2014, indicated Patient A was to be given, "Copy of labs (laboratory results) and imaging (CT scan of abdomen), and to follow up in 1-2 days with outpatient surgery." A review was conducted on April 1, 2014 at 3:00 PM, of the written discharge instructions provided to Patient A, dated February 6, 2014 at 9:04 AM. The instructions were written in English, and instructed Patient A to "follow up with primary care doctor in 1-2 days, return to ER if symptoms worsen." There was no documented evidence a translator had been used in the discharge process. There was no typed or handwritten instruction related to Patient A receiving laboratory and imaging results, or to be seen in outpatient surgery as instructed by the ER physician.This failure placed Patient A at risk of not receiving the appropriate, and prescribed follow up care for her abdominal pain.During an interview with the ER director on April 1, 2014 at 2:50 PM, she was asked if the facility's computer system was able to print out discharge instructions in Spanish. She said that they were able to, and also could use interpreters.A review of the facility policy and procedure titled, " Discharge form the Emergency Department,"dated, February 2012, indicated under,"policy," that "The registered nurse is to review the instructions with the patients, or responsible person to be certain that they understand the instructions.." The policy further addressed under, "points to emphasize," that, "It is important to assess the individual's ability to read and understand instructions related to cultural,..Translators are to be utilized if the patient or caregiver has limited or no English fluency."

Outcome:

Deficiency cited by the California Department of Public Health: Patients' Rights

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: H5VT11.02

2 other violations reported on the same date. Note that other citations may be about the same event: HG5X11.01, ZARM11.01