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Based on observations, records reviewed, and interviews, the Hospital failed to assure 1 of 12 sampled patients (Patient #1), that quality improvement activities thoroughly investigated morgue capacity for refrigerating all deceased patients. The Hospital failed to identify opportunities for improvement and implement preventative measures after Patient #1 died on 3/19/16. The Hospital did not adequately refrigerate Patient #1's body for 3 days after death and this was not consistent with acceptable standards of practice.

Findings include:

The Death Certificate indicted that Patient #1 died at 11:33 A.M. on 3/19/16.

The Surveyor interviewed the Complainant at 9:50 A.M. on 4/26/16. The Complainant said the Hospital did not properly store Patient #1's body after death. The Complainant said the funeral home was not able to fulfill family wishes for an open viewing because Patient #1's body was too decomposed. The Complainant said the Patient Advocate told the Complainant that the Hospital left Patient #1's body in a room unpreserved because the morgue was full with two other bodies and there was no room for Patient #1.

The Surveyor interviewed the Patient Advocate at 8:45 A.M. on 4/28/16. The Patient Advocate said that, on 3/22/16, the Hospital received a complaint that Patient #1's deceased body was too decomposed for an open viewing and notified Senior Leadership on 3/22/16. The Patient Advocate said the Hospital identified the issue as a complaint and resolved the issue as a complaint. The Patient Advocate said the Hospital closed the complaint on 3/24/16.

The Surveyor interviewed the Funeral Home Director at 1:00 P.M. on 4/28/16. The Funeral Home Director said when he received Patient #1's body on 4/22/16, Patient #1 was extremely bloated and had skin slippage which are signs of decomposition. In addition, the Funeral Home Director said that the temperature in the Morgue at the Hospital was extremely hot. The Funeral Home Director said that he notified Patient #1's family that an open viewing of Patient #1 was not possible do to the decomposition of the deceased.

The Surveyors interviewed the Quality Director at 9:00 A.M. on 4/27/16. The Quality Director said the Hospital knew that they did not place Patient #1 in a refrigerator in the morgue. The Quality Director said that Patient #1 died at 2:18 P.M. on 3/19/16 and Patient #1's body was released to the funeral home at 1:40 P.M. on 3/22/16 (3 days).

The Surveyors interviewed the Chief Operating Officer (COO) and Case Manager Director at 10:00 A.M. on 4/27/16. The COO and Case Management Director said that, at the time of Patient #1's death, two other deceased patients occupied the two morgue refrigerators. The COO and the Case Management Director said the Hospital had no documentation that the Hospital had ever placed Patient #1 into a morgue refrigerator after the time of death. The COO and the Case Management Director said that the Hospital did not have enough morgue refrigerators.

The document titled Morgue Log, dated 3/19/16, indicated Security personnel entered Patient #1 into the Morgue Log at 2:18 P.M. on 3/19/16. The Morgue Log did not indicate if Patient #1 was ever placed into a refrigerator from the time into the morgue at 2:18 on 3/19/16 through release of Patient #1's body to the funeral home at 1:14 P.M. on 3/22/16.

The Surveyors interviewed the Chair of Pathology & Laboratory Medicine, the Laboratory Administrative Director and COO at 1:30 P.M. on 4/27/16. The Chair of Pathology & Laboratory Medicine, the Laboratory Administrative Director and COO said the Security Department was responsible for the deceased patient in the morgue and that Case Management Department was responsible for arrangements of the deceased patient for final destination (funeral home). The Chair of Pathology & Laboratory Medicine, the Laboratory Administrative Director and COO said that the Laboratory & Pathology Department was not responsible for the deceased patient body; they were responsible only for monitoring the temperature of the refrigerator.

The document titled Table of Contents for the Laboratory & Pathology Policy & Procedure Manuals (undated) did not indicated policies or procedures for the Hospital morgue.

The Surveyor interviewed the Hospital President at 11:00 A.M. on 4/28/16. The Hospital President said that she became aware of the issue on 4/5/16 (Patient #1 died on 3/19/16). The Hospital President said she told Hospital personnel that corrective actions included that no one could leave for the day when there were more than 2 deceased patients in the Hospital morgue until resolution by placement of the deceased into a funeral home; or transport to another Hospital morgue with capacity within the Hospital System.

The Surveyors observed at 8:30 A.M. on 4/27/16 two refrigerators for deceased patients in the Hospital's morgue.

The Surveyor interviewed the Facilities Vice President at 7:30 A.M. on 4/28/16. The Facilities Vice President said that the Hospital should refrigerate a deceased body within 6 hours of death. The Facilities Vice President said he became aware of the morgue capacity issue when the Hospital President notified him on 4/27/16. The Facilities Vice President said the Hospital's immediate corrective action included renting a portable morgue refrigeration unit and the refrigeration unit was expected to be at the Hospital by 9:00 A.M. on 4/28/16 (the Survey exit date and more than one month after Patient #1's death). The Facilities Vice President said that corrective action included moving an unused 3 to 4 capacity morgue-refrigeration unit to the Hospital and that the Hospital expected installation of the morgue-refrigeration completed within approximately 7-10 days.

Based on observations, records reviewed, and interviews the Hospital failed to have enough morgue refrigerators to preserve 1 of 12-sampled patient's (Patient #1's) body after death on 3/19/16, for 3 days and this was not consistent with acceptable standards of practice.

Findings include:

The Surveyor interviewed the Complainant at 9:50 A.M. on 4/26/16. The Complainant said the Patient Advocate told the Complainant that the Hospital left Patient #1's body in a room unpreserved because the morgue was full with two other bodies and there was no room for Patient #1.

The Surveyors interviewed the Quality Director at 9:00 A.M. on 4/27/16. The Quality Director said the Hospital knew that they did not place Patient #1 in a refrigerator in the morgue.

The Surveyors interviewed the Chief Operating Officer (COO) and Case Manager Director at 10:00 A.M. on 4/27/16. The COO and the Case Management Director said that the Hospital did not have enough morgue refrigerators.

The document titled Morgue Log, dated 3/19/16, indicated Security personnel entered Patient #1 into the Morgue Log at 2:18 P.M. on 3/19/16. The Morgue Log did not indicated if Patient #1 was ever placed into a refrigerator from the time into the morgue at 2:18 on 3/19/16 through release of Patient #1's body to the funeral home at 1:14 P.M. on 3/22/16.

The Surveyors observed at 8:30 A.M. on 4/27/16 two refrigerators for deceased patients in the Hospital's morgue.

Based on observations, records reviewed, and interviews, the Hospital failed to assure 1 of 12 sampled patients (Patient #1), that quality improvement activities thoroughly investigated morgue capacity for refrigerating all deceased patients. The Hospital failed to identify opportunities for improvement and implement preventative measures after Patient #1 died on 3/19/16. The Hospital did not adequately refrigerate Patient #1's body for 3 days after death and this was not consistent with acceptable standards of practice.

Findings include:

The Death Certificate indicted that Patient #1 died at 11:33 A.M. on 3/19/16.

The Surveyor interviewed the Complainant at 9:50 A.M. on 4/26/16. The Complainant said the Hospital did not properly store Patient #1's body after death. The Complainant said the funeral home was not able to fulfill family wishes for an open viewing because Patient #1's body was too decomposed. The Complainant said the Patient Advocate told the Complainant that the Hospital left Patient #1's body in a room unpreserved because the morgue was full with two other bodies and there was no room for Patient #1.

The Surveyor interviewed the Patient Advocate at 8:45 A.M. on 4/28/16. The Patient Advocate said that, on 3/22/16, the Hospital received a complaint that Patient #1's deceased body was too decomposed for an open viewing and notified Senior Leadership on 3/22/16. The Patient Advocate said the Hospital identified the issue as a complaint and resolved the issue as a complaint. The Patient Advocate said the Hospital closed the complaint on 3/24/16.

The Surveyor interviewed the Funeral Home Director at 1:00 P.M. on 4/28/16. The Funeral Home Director said when he received Patient #1's body on 4/22/16, Patient #1 was extremely bloated and had skin slippage which are signs of decomposition. In addition, the Funeral Home Director said that the temperature in the Morgue at the Hospital was extremely hot. The Funeral Home Director said that he notified Patient #1's family that an open viewing of Patient #1 was not possible do to the decomposition of the deceased.

The Surveyors interviewed the Quality Director at 9:00 A.M. on 4/27/16. The Quality Director said the Hospital knew that they did not place Patient #1 in a refrigerator in the morgue. The Quality Director said that Patient #1 died at 2:18 P.M. on 3/19/16 and Patient #1's body was released to the funeral home at 1:40 P.M. on 3/22/16 (3 days).

The Surveyors interviewed the Chief Operating Officer (COO) and Case Manager Director at 10:00 A.M. on 4/27/16. The COO and Case Management Director said that, at the time of Patient #1's death, two other deceased patients occupied the two morgue refrigerators. The COO and the Case Management Director said the Hospital had no documentation that the Hospital had ever placed Patient #1 into a morgue refrigerator after the time of death. The COO and the Case Management Director said that the Hospital did not have enough morgue refrigerators.

The document titled Morgue Log, dated 3/19/16, indicated Security personnel entered Patient #1 into the Morgue Log at 2:18 P.M. on 3/19/16. The Morgue Log did not indicate if Patient #1 was ever placed into a refrigerator from the time into the morgue at 2:18 on 3/19/16 through release of Patient #1's body to the funeral home at 1:14 P.M. on 3/22/16.

The Surveyors interviewed the Chair of Pathology & Laboratory Medicine, the Laboratory Administrative Director and COO at 1:30 P.M. on 4/27/16. The Chair of Pathology & Laboratory Medicine, the Laboratory Administrative Director and COO said the Security Department was responsible for the deceased patient in the morgue and that Case Management Department was responsible for arrangements of the deceased patient for final destination (funeral home). The Chair of Pathology & Laboratory Medicine, the Laboratory Administrative Director and COO said that the Laboratory & Pathology Department was not responsible for the deceased patient body; they were responsible only for monitoring the temperature of the refrigerator.

The document titled Table of Contents for the Laboratory & Pathology Policy & Procedure Manuals (undated) did not indicated policies or procedures for the Hospital morgue.

The Surveyor interviewed the Hospital President at 11:00 A.M. on 4/28/16. The Hospital President said that she became aware of the issue on 4/5/16 (Patient #1 died on 3/19/16). The Hospital President said she told Hospital personnel that corrective actions included that no one could leave for the day when there were more than 2 deceased patients in the Hospital morgue until resolution by placement of the deceased into a funeral home; or transport to another Hospital morgue with capacity within the Hospital System.

The Surveyors observed at 8:30 A.M. on 4/27/16 two refrigerators for deceased patients in the Hospital's morgue.

The Surveyor interviewed the Facilities Vice President at 7:30 A.M. on 4/28/16. The Facilities Vice President said that the Hospital should refrigerate a deceased body within 6 hours of death. The Facilities Vice President said he became aware of the morgue capacity issue when the Hospital President notified him on 4/27/16. The Facilities Vice President said the Hospital's immediate corrective action included renting a portable morgue refrigeration unit and the refrigeration unit was expected to be at the Hospital by 9:00 A.M. on 4/28/16 (the Survey exit date and more than one month after Patient #1's death). The Facilities Vice President said that corrective action included moving an unused 3 to 4 capacity morgue-refrigeration unit to the Hospital and that the Hospital expected installation of the morgue-refrigeration completed within approximately 7-10 days.

Based on observations, records reviewed, and interviews the Hospital failed to have enough morgue refrigerators to preserve 1 of 12-sampled patient's (Patient #1's) body after death on 3/19/16, for 3 days and this was not consistent with acceptable standards of practice.

Findings include:

The Surveyor interviewed the Complainant at 9:50 A.M. on 4/26/16. The Complainant said the Patient Advocate told the Complainant that the Hospital left Patient #1's body in a room unpreserved because the morgue was full with two other bodies and there was no room for Patient #1.

The Surveyors interviewed the Quality Director at 9:00 A.M. on 4/27/16. The Quality Director said the Hospital knew that they did not place Patient #1 in a refrigerator in the morgue.

The Surveyors interviewed the Chief Operating Officer (COO) and Case Manager Director at 10:00 A.M. on 4/27/16. The COO and the Case Management Director said that the Hospital did not have enough morgue refrigerators.

The document titled Morgue Log, dated 3/19/16, indicated Security personnel entered Patient #1 into the Morgue Log at 2:18 P.M. on 3/19/16. The Morgue Log did not indicated if Patient #1 was ever placed into a refrigerator from the time into the morgue at 2:18 on 3/19/16 through release of Patient #1's body to the funeral home at 1:14 P.M. on 3/22/16.

The Surveyors observed at 8:30 A.M. on 4/27/16 two refrigerators for deceased patients in the Hospital's morgue.