HospitalInspections.org

Based on policy review, closed medical record review, grievance file review, and staff and physician interview the hospital failed to notify a patient's family of the patient's death for 1 of 4 sampled expired patients (Patient #2).

The findings include:

Review of current hospital policy entitled "Patient Rights and Responsibilities" dated 02/2011 revealed, "...A patient has the right to have his/her family member or representative...notified of his/her admission...unless the patient requests this not be done...."

Review of current hospital policy entitled "Death - Post Mortem Care" dated 10/2007 revealed, "...3. The physician who makes the pronouncement of death must notify the patient's family or legal guardian. If the family or legal guardian is not present in the Hospitals at the time of death, the physician will contact the family or legal guardian, and ascertain whether or not he/she wishes to come to the Hospitals to view the body...."

Review of current hospital policy entitled "Morgue Procedure For Determining The Disposition Of An Unclaimed Body" dated 05/28/2010 revealed, "...1. When a body has been in the cooler for 10 days and we have no Notification of Death, Death Query or Death Certificate from MIM (Medical Information Management) we deem the decedent as unclaimed. 2. We call MIM to find out about the decedent's family history. 3. If MIM finds out there is a family, and they definitely cannot afford a funeral and it sounds like they fall into a poverty level classification, we contact (the hospital's) social services department and explain the situation and provide family contact information so they can help with a solution....4. If MIM finds out there is a family and they do not want to pay for any disposition, we call the family and explain to them we have to call (Name) County Social Services Department...who will contact them. 5. If MIM finds out there is no family or any acquaintances...we call (Name) County Social Services Department for disposition of remains....(Name) County has another 10 days to try and contact family members....A cremation organization will pick up the body after everything is cleared with (Name) County."

Medical record review for Patient #2 revealed a 75 year-old male that was admitted to the Neurosurgical Intensive Care Unit on 12/05/2010 at 0000 with subdural hemorrhage (bleeding around the brain). Record review revealed the patient had been transferred from an outside hospital (OSH) for specialty care. Record review revealed a copy of the patient's medical record from the OSH was sent to the hospital with the patient. Review of the OSH medical record revealed the patient's granddaughter (including a North Carolina address and phone number) was listed as "Person to Notify". Review of the OSH medical record revealed the patient's son was listed as next of kin. Further review of the OSH record revealed the patient's son's address (in Colorado) and phone number were listed. Review of Case Manager's notes dated 12/05/2010 at 1122 revealed, "...recd (received) call from (Nurse Practitioner) - pt (patient) w/poor prognosis and can't reach family. Wanted any other numbers. None available in Canopy (Case Management's computer system) besides main number. Pt unresponsive. Suggested call hospital police to check if there are any contact numbers in pt's wallet if one is in hospital safe. No other needs identified." Review of physician's progress notes (signed by resident and attending physicians) dated 12/05/2010 at 2158 revealed, "...Brain Death Exam performed at 1925 on 12/5/2010. Current exam is compatible with brain death....Numerous attempts have been made by multiple staff members to contact family, including sending a sheriff patrol car out to pt's home to try to locate family. So far no family has been able to be contacted...." Record review revealed a second Brain Death Examination was performed on 12/06/2010 at 0729, at which time the neurologist physician declared the patient to be brain dead. Review of physician's progress notes (signed by resident and attending physicians) dated 12/06/2010 at 0855 revealed, "...pt had 2 brain death exams which were compatible with brain death....Current exam is compatible with brain death....Numerous attempts have been made by multiple staff members to contact family, including sending a sheriff patrol car out to pt's (patient's) home to try to locate family. So far no family has been able to be contacted...." Review of the physician's discharge summary (signed by resident and attending physicians) dated 12/06/2010 at 1155 revealed, "...Numerous attempts have been made by multiple staff members to contact family, including sending a sheriff patrol car out to pt's home to try to locate family without success. The patient was thus extubated, and he expired at 0730 on 12/6/2010." Record review revealed nursing staff took the patient's body to the morgue on 12/06/2010 at 0920. Record review revealed no other documented attempts by staff or physicians to contact the patient's family after he died.

Review of a grievance filed on 12/16/2010 by Patient #2's son revealed, "Patient's son called Patient relations to voice the following grievance: (Son) stated patient was airlifted...to (hospital) on 12-4-10 and died on 12-6-10. (Son) stated on 12-4-10 patient called 911 and EMS (Emergency Medical Services) went to the house where there was a list of names of family members and phone numbers on the table. (Son) stated on 12-10-10 they could not get a hold of patient and stated called sheriff's office. (Son) stated that (hospital) neglected leaving a message at (other son's phone) asking to call (hospital) for an important matter. (Son) stated that (hospital) would have cremated patient if they would not had been diligent on tracking his father's whereabouts...." Review of the file revealed the Patient Relations staff investigated the patient's son's concerns and found documentation that staff had appropriately attempted to contact all available family at the numbers in the patient's chart and had sent a sheriff patrol to the patient's home in an attempt to locate family. File review revealed a letter of resolution was sent to the patient's son on 12/30/2010. File review revealed the patient's son sent a grievance letter dated 01/26/2010 to the hospital. Review of the letter revealed, "...had (hospital) completed due diligence and made some phone calls to personnel listed on his (OSH) medical records they could have indeed contacted us and we could have been with him before he died. Our father laid in your Morgue from 6-10 December without ANYONE from (hospital) trying to make contact with our family. The only way we knew something was wrong was when my wife called 911 for the Sheriff to do a well check. They notified us there'd been a 911 call on 4 December in the morning, we called the hospitals and had to press your staff to look in the Morgue when they couldn't find any records of him being there...." File review revealed Patient Relations staff investigated and responded to the patient's son in a letter dated 02/18/2011. File review revealed during the course of the investigation, no calls from the hospital's land line could be traced to either of the 2 family numbers listed in the patient's record before 12/10/2010, when the patient's son spoke with Patient Relations staff. File review revealed clinical staff sometimes used cell phones, which wouldn't have been traced.

Interview on 05/25/2011 at 0920 with a registered nurse (RN) member of the hospital's transport team revealed the RN assisted with the transport of Patient #2 from the OSH to the Neurosurgical Intensive Care Unit (NICU) on 12/05/2010. Interview revealed the nurse at the OSH reported that they had not been able to contact the patient's family. Interview revealed the RN told the receiving nurse in NICU that the family had not been contacted and gave the nurse the medical record from the OSH.

Interview on 05/24/2011 at 1400 with a Nurse Practitioner (NP) from Neurosurgical Intensive Care Unit (NICU) revealed the NP worked during the dayshift on 12/05/2010. Interview revealed, "I tried to call (the patient's family) several times that day. Two or three times. I tried two different numbers. One was disconnected. The second one went to an answering machine. I didn't leave a message due to patient confidentiality....I wasn't sure if it was the right number. I wasn't sure if it was his family." Interview revealed the NP wasn't sure if she called from landline or cell phone.

Interview on 05/24/2011 at 1200 with the Case Manager revealed the Nurse Practitioner (NP) called her on 12/05/2010 and told her they couldn't reach the patient's family. Interview revealed the Case Manager told the NP to call the hospital police and see if there were other numbers in the patient's wallet and to call the Sheriff's department in the area where the patient lived. Interview revealed, "I had no contact with the family. I didn't try to contact them."

Interview on 05/24/2011 at 1430 with the neurosurgery resident physician that authored progress notes on 12/05/2010 and 12/06/2010 revealed the resident physician tried to call the patient's family while the patient was in NICU. Interview revealed, "I googled him and we found someone in Colorado. I tried to call and either didn't get an answer or the number didn't work. I also tried to call the numbers in the record, one was a son in Colorado. I found one other (patient's last name) listed and tried that number. There was no answer. I called the Sheriff in his county to ride by his house to try to locate family." Interview revealed the resident physician did not try to call the patient's family after the patient died because she wasn't on duty then.

Interview on 05/25/2011 at 1125 with the patient's attending physician revealed, "I didn't try to call his family. The residents and nurses tried."

Interview on 05/25/2011 at 1130 with the attending neurologist that declared the patient to be brain dead on 12/06/2010 at 0729 revealed, "There was an issue with contacting the family. The Nurse Practitioner...called and got an answering machine. (The resident physician) had a sheriff go to his home...and she also called a number and got an answering machine....I spoke with the team and discussed that we had made multiple attempts to contact family without success. We decided to proceed with extubation (removal of life support). He was pronounce (dead) and sent to the morgue. I'm not sure if anyone tried to contact his family (on the morning of the patient's death)....I did not try to contact his family myself. I knew they had tried (on the day before the patient's death). I'm unsure if anyone tried (to contact the family) after the patient died."

Interview on 05/25/2011 at 1100 with the registered nurse (RN) who was present when the patient died revealed the nurse took the patient's body to the morgue at about 0920 on 12/06/2010. Interview revealed, "I never called his family or saw anyone else call them. I don't recall reporting to anyone that his family had not been notified."

Interview on 05/24/2011 at 1015 with Patient Relations staff revealed the staff member had received a call from the patient's son on 12/10/2010. Interview revealed, "He said he was trying to find his dad....He knew he was here and wanted to make sure he was okay. I found (in the computer) the patient was dead. He had expired on 12/6. I told him. They (the family) cried for a few minutes, then he asked me when he died and who had tried to contact them. I told him let me look through the notes....I saw that they had tried to call the other son's number....The granddaughter's number was disconnected per the social worker....(The other son) confirmed there was a number that they tracked back to this hospital, but there was no message (left) so they didn't call back....(Per their caller ID) only one call was made to his number....I told him the patient was still in the morgue and gave him the number. He asked if he had been cremated and I told him I wasn't sure of the policy, but sometimes that does happen after a certain amount of time. I told him the best thing to do was to call the morgue." Interview revealed the staff member had investigated the family's concerns and on 02/16/2011 held a group meeting with clinical staff members involved in the patient's care. Interview revealed the nurse practitioner who reached the patient's son's answering machine had been afraid of violating HIPAA (privacy rules) and therefore didn't leave a message. Interview revealed, "We decided we will now start leaving messages when we call, no patient information but a message to call a contact person at the hospital." Interview revealed the staff member thought the morgue had tried to contact the family, but when she investigated she found that the morgue staff didn't have a protocol for contacting families, but they thought either clinical staff or the Medical Information Management (MIM) Department contacted families.

Interview on 05/24/2011 at 1300 with morgue staff revealed, "We're not contacting families at all (in the morgue). That's not our role. The only time we would contact them is if an autopsy form (permit) was not filled out completely....We don't know anything about what's going on with the family side....If we get a call from family regarding funeral home, we refer them to Medical Information Management." Further interview revealed morgue staff would attempt to contact families of unclaimed bodies that were in the morgue for more than 10 days. Interview revealed, "If a body is not claimed after possibly a couple of more weeks then the State of North Carolina claims the body as indigent and the body gets cremated, but the family can't get the ashes back....We call (name) in Risk Management first and tell her we've had no contact and she makes a decision to call the State." Interview revealed the staff member had tracked Patient #2's stay in the morgue and found that a resident physician from the Medical Examiner's (ME's) office had performed an external examination on 12/07/2010. Interview revealed, "There were no attempts to contact family. (The body) was only stored in our morgue for 4 days, so there was no need to call due to such a short time (not 10 days )."

Interview on 05/24/2011 at 1330 with the resident physician who performed the external examination of Patient #2's body on 12/07/2010 revealed, "I did not try to contact his family....We usually do not contact family from the ME office."

Interview on 05/24/2011 at 1400 with the Assistant Director of Medical Information Management (MIM) revealed there was a designated area in MIM, referred to as the "Death Desk", where all paperwork involved with a death was completed and coordination with funeral homes was done. Interview revealed, "We don't contact families....Nothing was done on our end to contact the family."


NC00071051