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Based on medical record review, facility policy review, observation, and staff interview, the Governing Body failed to ensure the overall operation of the hospital complied with established facility policies related to morgue assist by Security Personnel and care of the postmortem infant and adult (A 063). This affected Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6.

Based on medical record review, facility policy review, observation, and staff interview, the Governing Body failed to ensure staff followed the current facility policies related to postmortem care of the infant and adult and morgue assist by the security department. This affected Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6. The facility census was 196.

Findings include:

Staff A, Chief Quality Officer and Staff G, Risk Officer, were interviewed on 08/30/16 at approximately 1:35 PM. According to Staff G a patient delivered a fetal demise at 24 weeks gestation, just after midnight on 08/20/16. An autopsy was ordered on 08/20/16 and the fetal remains were taken to the morgue that day. When the funeral home arrived at the facility to pick up the fetal remains for a private burial on 08/22/16, the remains were not provided to the funeral home, as there was a consent for an autopsy and it had not yet been completed. On 08/23/16 the patient was called and informed per facility policy, an autopsy could be completed but it would be at the patient's expense. The patient became upset, hanging up on the hospital representative. On the evening of 08/23/16 another body was delivered to the morgue by an LPN, a transporter, and a security guard. When the top body refrigerator was opened, a white bag was noted in the refrigerator. The security guard, believing the bag was garbage left behind from the previous body, threw the bag in the garbage can.

The patient was called again on 08/25/16 and asked if an autopsy was still desired or if the fetus could be picked up by the funeral home. The patient requested the funeral home pick up the infant. The funeral home arrived at approximately 4:30 PM on 08/25/16 to pick up the remains of the fetus, but there was no sign of the fetus. Staff began to search for the missing fetus into the evening. The search continued on 08/26/16.

It is when staff members that came into contact with the fetus were interviewed, it was discovered that the body bag holding the infant remains was discarded by a security guard. Despite a thorough search of the facility and search of the linen facility, the remains have not been found. Staff A stated that the facility has contacted the local landfill and the coordinates of the location of the facility's garbage have been identified. The facility is working with EPA (Environmental Protection Agency) officials to search the landfill at identified coordinates. When Staff G was asked for documentation of an action plan, he/she stated: "We have just started our investigation. We only have rough draft notes. There is nothing in writing." Staff A and Staff G were requested to provide what they had, no matter the format.

1. The medical record of Patient #1 was reviewed on 08/30/16 at 2:30 PM. Review of the medical record revealed that Patient #1, a Gravida 3 Para 1 at 24.5 weeks gestation, was admitted to the facility's maternity unit on 08/19/16 at 12:35 PM. Although the patient was 24.5 weeks gestation by dates, an ultrasound report four days prior, on 08/15/16, revealed a 20 week fetus. The ultrasound report further diagnosed an intrauterine fetal demise with no cardiac activity noted. The medical record noted that the patient declined admission for induction of labor at the time of diagnosis, but presented four days later on 08/19/16 for an induction of labor with Cytotec.

The delivery summary stated that the fetal demise was delivered at 1:55 AM on 08/20/16 without signs of life. The fetus was noted to weigh 7.35 ounces (209 grams). The placenta delivered three minutes later, at 1:58 AM. A consent for a full autopsy was noted in the medical record. The form was signed and dated by the patient on 08/20/16 at 2:00 AM. The Prenatal Loss Checklist form, timed 2:40 AM, also gave the name and number of a private funeral home the fetal remains should be released to for burial. The patient recovered, was provided discharge instructions, and was discharged home on 08/20/16 at 2:14 PM.

Staff F, the Staff Nurse who cared for the patient, was interviewed on 08/31/16 at approximately 2:11 PM via phone. He/She stated that the fetus remained in the room with the patient for several hours after birth. The fetus was removed from the room, placed in a body bag with an identification tag attached to the zipper, and delivered to the laboratory. Staff F described placing the 7.35 ounce fetus in the white body bag. When asked if the fetus was placed or wrapped in anything prior to being placed in the body bag, he/she stated: "No, I just put the infant in the bag." Staff F stated that it is not customary to deliver infant/fetal remains to the laboratory, but reported, because of the parents request for an autopsy, staff from the laboratory requested the fetus be delivered to the lab instead of the morgue. Staff F reported delivering the body bag with the fetus inside to the lab at approximately 6:00 AM on 06/20/16. Staff F further stated that a copy of the patient's medical record and expiration paperwork were placed in an envelope and delivered with the fetus.

Staff D, the lab technician, was interviewed on 08/31/16 at 1:30 PM. He/She stated the infant was delivered to the lab between 6:00 AM and 7:00 AM on Saturday, 08/20/16. Staff D stated that he/she spoke with the pathologist via phone at approximately 6:30 AM and informed him/her that the remains of the infant were in the lab. He/She further informed the Pathologist that both an autopsy and chromosomal analysis on the fetus were ordered to be performed. The lab technician stated that the pathologist instructed him/her to place the fetal remains in the top body refrigerator of the morgue. The lab technician further stated that he/she and another lab technician delivered the fetus to the morgue at approximately 6:45 AM. Staff D was asked if he/she called a member of security to unlock the morgue as required by facility policy. He/She reported accessing the lab via the histology door using the key pad. He/She denied calling the security department stating: "I was unaware that we needed to call Security." The fetus was placed in the top body refrigerator as instructed by the pathologist. Staff D was asked if the body of the fetus was signed in on the Morgue Sign-In/Out log. Staff D again reported being unaware of the facility policy requiring each body to be signed in on the log.

Staff E, the facility Pathologist, was interviewed on 08/31/16 at 3:05 PM. He/She confirmed being called by the lab technician early in the morning on 08/20/16. He/She stated that he/she originally instructed the lab technician that the autopsy and chromosomal analysis could both be completed on Monday, 08/22/16. Staff E stated that he/she later changed his/her mind and decided to perform the chromosomal analysis that day, realizing that the chromosomal analysis might get better results if fresh tissue was used. Staff E reported arriving to the morgue on the evening of 08/20/16. He/She retrieved the fetus from the top body refrigerator, removed the fetus and retrieved the sample. Staff E placed the fetus back in the white body bag and placed the bag back in the top body refrigerator. He/She reported that the fetus was intact although "slightly macerated."

The facility policy titled Postmortem Care of Infants was reviewed on 08/30/16 at 04:20 PM. According to the policy staff must complete the Patient Expiration Record when parents have chosen to privately bury an infant. The original should go with the body and one should remain in the mother's medical record. Staff are then instructed to attach one morgue tag to the ankle of the infant, wrap the infant in a plastic shroud or blanket then attach one morgue tag on the outside of the shroud. Security is notified so the morgue can be unlocked. The infant is then taken to the morgue and the Morgue Sign-In/Out sheet, located on the wall, is completed with the patient's name, funeral home, and the staff member's initials.

The Patient Expiration Record for the fetus was reviewed on 08/30/16. The lines for the time and date that Lifebanc was notified of the patient's death were noted to be blank. Under the heading titled Disposition of Body, the staff member filling out the form is given the choice to check yes or no next to the question if the body is in the morgue. Also under this category, the staff member is asked if the HUB, the office for tracking and logging whereabouts of bodies, was notified of the disposition of the body. Neither question was answered, leaving both fields blank. There was also a signature line for the staff member that completed the form to sign and date, which were also noted to be blank.

The morgue was toured on 08/31/16 at 1:30 PM. There were two metal refrigerators, one on top of the other, observed. The refrigerators were not opened at the time of the tour. The Morgue Sign-In/Out sheet was noted to be attached to a clipboard hanging from the wall.

The Morgue Sign-In/Out log was reviewed on 08/31/16 at 9:00 AM. The log was noted to have a heading first, for body name. The next heading was for body bag type and requested the person completing the form circle whether a white bag, black bag, no bag, or red bag/box was used. There were separate boxes for the date and time the body was in and out of the morgue. The last heading was titled ambulance/carrier in and funeral home/carrier out.

Staff I, The Emergency Department Manager, was interviewed on 08/31/16 at 4:10 PM. He/She stated that he/she had only known staff in the Emergency Department to use white body bags in pediatric and adult size. Staff I stated that the black bags may be used in the event a person is pronounced dead at the scene, placed in a black body bag and transported to the hospital for family to identify. 'No bag' was described being selected when the deceased person is too large to fit in a white bag. Staff I stated that the red bag and box are for fetuses below 20 weeks gestation. The entry for the missing fetus was noted. The choice of the white body bag was circled and the fetal remains were signed into the morgue on 08/22/16. There were no initials from the staff member logging the remains in the morgue. Out of the nine bodies signed into the log, only two were noted to list the names of the staff members that brought the bodies into the morgue.

Staff A was interviewed on 08/31/16 at 9:45 AM. He/She stated that it is believed when the funeral home unsuccessfully attempted to pick up the fetal remains on 08/22/16, a security guard noted the pediatric size body bag in the top body refrigerator and noted the body had not been signed in using the Morgue Sign-In/Out log and placed the name of the fetus in the appropriate field and placed that day's date, as he/she was unsure of when the fetus was actually placed in the morgue.

2. The medical record of Patient #2 was reviewed on 08/31/16 at 8:30 AM. Review of the medical record revealed that Patient #2, a Gravida 1 Para 0 at 20 weeks gestation, was admitted to the maternity unit on 08/20/16 at 2:35 PM with complaints of cramping and passing blood clots. A nursing note stated there was difficulty finding a fetal heart rate. A fetal demise was confirmed by ultrasound. The labor flowsheet stated that Cytotec was inserted at 6:18 PM and again at 9:50 PM to augment labor. The delivery summary stated that the fetal demise was delivered on 08/21/16 at 12:18 AM weighing 305 grams.

The Patient Expiration Record revealed that, although the yes box was checked to the question if the body was in the morgue, the question as to if the HUB was notified of the disposition of the fetal remains was not answered. The morgue sign-in/out log was also reviewed. The log revealed that the fetus of Patient #2 was signed in on 08/21/16 at 6:30 AM but there were no initials identifying which staff member transported the fetus to the morgue. The log further stated that the fetus was in a red bag/box.

Staff B was interviewed on 08/31/16 at 1:00 PM. Staff B confirmed that the facility policy for the care of a postmortem infant was not followed by staff involved in the care of Patient #1 and Patient #2, as the Patient Expiration Record was not completed and missing disposition of the body and HUB notification as to the whereabouts of the bodies. It was also confirmed that the fetus of both patients were incorrectly logged into the morgue.

Staff H, the facility's security guard that believed the fetal remains of Patient #1 to be garbage, was interviewed on 08/31/16 at 6:15 PM via phone. According to Staff H, he/she was called by an Emergency Department staff nurse during the evening of 08/23/16 and asked to unlock the morgue door as there was a death and the body needed to be placed in one of the body refrigerators. He/She reported going to the morgue with the nurse and a transporter at approximately 7:00 PM. When he/she opened the top body refrigerator, he/she noted a white bag that resembled a garbage bag. Staff H checked the Morgue Sign-In/Out log sheet and reported there being no bodies yet to be signed out on the log. Staff H denied opening the bag, but reported feeling around the bag and when nothing was felt, believed the bag was indeed garbage and threw it into the garbage can.

The facility's policy for maintaining the security of the morgue and it's operation entitled "Morgue Assist" was reviewed on 08/31/16 at 12:05 PM. According to the policy, security officers must assist in transporting deceased persons to or from the morgue by directing and/or escorting. Nothing in the policy stated that the security guard should throw anything from a refrigerated body compartment in the garbage can.

Administrative staff were interviewed on 08/31/16 at 7:30 PM. It was confirmed that the facility's policy for security guard morgue assist was not followed, as the policy did not instruct the removal of any bag from a refrigerated body compartment, only the assistance in transporting bodies and unlocking the morgue door was outlined.

3. The medical record of Patient #3 was reviewed on 08/31/16 at 4:00 PM. According to the Patient Expiration Record, the patient was pronounced dead by an emergency department physician on 08/23/16 at 3:53 PM. The Patient Expiration Record did not state if the body was placed in the morgue or if the HUB was notified of the disposition, as required by facility policy.

Review of the Morgue Sign-In/Out Log revealed that the body was picked up by a funeral home on 08/30/16 at 2:30 PM, there was no signature and date by the funeral home representative noting receipt of the body. There was also no signature by the staff member that released the body. Review of the Morgue Sign-In/Out Log also revealed that there were no initials of the staff member that signed the body into the morgue.

4. The medical record of Patient #4 was reviewed on 08/31/16 at 4:20 PM. According to the Patient Expiration Record, the patient expired on 08/16/16 at 5:50 PM. The disposition of the body did not state if the body was in the morgue or if the HUB was notified of the disposition of the body. Review of the morgue log lacked initials of the staff member that transported the body to the morgue.

5. The medical record of Patient #5 was reviewed on 08/31/16 at 4:40 PM. According to the Patient Expiration Record, the patient expired on 08/27/16 at 5:44 PM. The HUB was not notified of the disposition of the body. It was further noted that there were no signatures of the funeral home representative the body was released to or the staff member releasing the body. The morgue log also lacked initials of the staff member that transported the body to the morgue.

6. The medical record of Patient #6 was reviewed on 08/31/16 at 5:00 PM. According to the Patient Expiration Record, the patient expired on 08/28/16 at 3:10 PM. Again, there were no signatures of the funeral home representative the body was released to or the staff member that released the body. There were no initials of the staff member that transported the body to the morgue.

The facility's policy for postmortem care and disposition of the adult body was reviewed on 08/31/16 at 9:30 AM. According to the policy, nursing has the general responsibility of preparing the body for removal to the morgue and completion of the Expiration Record. The transporter is responsible for removing the body, transporting to the morgue and verifying placement of the Expiration Record with the body, and appropriately logging the body into the morgue. Security staff are responsible for assessing the secure area of the morgue. It was confirmed on 08/31/16 at 05:20 PM that the facility policy for postmortem care and disposition of the adult body was not followed as the Patient Expiration Records of four patients were not completed and the morgue log was not initialed by the staff member transporting the body to the morgue.

This deficiency substantiates Substantial Allegation #OH00086613.