The eighty-one year-old patient has been deaf since birth. She communicates proficiently in American Sign Language (ASL) but has only a limited ability to communicate in written and spoken English.

    After hip surgery she was transferred from the hospital, where an ASL interpreter was provided for her as needed, to an assisted living facility that also offers physical rehabilitation services. She spent thirteen days in the facility for physical therapy for her hip. On admission to the facility she was provided with a communication board and paper and writing utensils to communicate with her caregivers.  She soon began writing notes that she needed an ASL interpreter. The facility's director of nursing dismissed her requests with a note back to her that they did not have an ASL interpreter and that they had been informed that she had communicated well in the past without an ASL interpreter. The facility apparently did phone a local community college and phoned a person who had volunteered in the past who knew ASL, but those leads were dead ends. No ASL interpreter was ever provided to the patient.

    Using handwritten notes the patient was able to get herself moved to a different room, to get someone to bring her an ice pack for her sore hip, to get a walker and to get them to turn on the closed-captioning on the TV in her room.

    Two years after discharge the patient filed a civil lawsuit against the facility al-leging violation of her rights as a disabled person guarantee by the US Americans With Disabilities Act, the US Rehabilitation Act, the US Fair Housing Act and Missouri's Human Rights Act.  The US District Court for the Eastern District of Missouri denied the facility's request for a summary judgment of dismissal as to all aspects of the case save for the Fair Housing Act allegations which were dismissed.  The Court also made a ruling defining the scope of expert testimony in a case of this nature.

    A healthcare facility is required by law to provide appropriate auxiliary aids and services to deaf and hard of hearing individuals where necessary to ensure effective communication, or face liability in a disability discrimination lawsuit.   A disability discrimination lawsuit does not focus on the quality of care or the ultimate medical outcome, but asks whether the patient experienced a less than equal opportunity for effective two-way communication with his or her caregivers.

    The type of auxiliary aid or service necessary to ensure effective communication will vary with the method of communication used by the individual, the nature, length and complexity of the communication involved and the context in which the communication takes place.  An interpreter might not be necessary simply for drawing a routine blood sample. On the other hand an interpreter would be necessary for more complex interactions like taking a medical history, explaining a diagnosis, expanding on the possible benefits and potential risks of a medical procedure or going over complicated discharge instructions, the Court said.

    The Court ruled that a jury could find that the facility was deliberately indifferent to this patient's needs as a disabled person.  A finding of deliberate indifference is a threshold issue for liability under Federal statutes. However, the Court also spoke to the issue of deliberate indifference in the context of liability for punitive damages under state law in Missouri, on top of liability for compensatory damages under Federal law.