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Based on clinical record review, select document review and interview it was determined the facility's professional staff failed to follow procedure and notify the hospital's Pathologist On-Call of an autopsy in one (1) of one (1) patient records with an ordered autopsy in the survey sample. Specifically, the hospital's Pathologist was not immediately notified of the need to conduct an autopsy (for more than 2 days) following a patient's death, patient #3.

The findings were:

Clinical records were reviewed in the hospital's Administrative conference room April 1 & 2, 2013 between the hours of 9 a.m. and 3 p.m.

The record for patient #3 revealed that the patient was admitted through the emergency room on 12/14/12 in cardiac arrest. Multiple attempts to stabilize the patient were unsuccessful and the patient expired in the the facility's ICU (Intensive Care Unit) on 12/14/12 at 5:37 p.m. A physician's order for an autopsy was ordered at 6 p.m. that same evening. A family member signed a consent for autopsy on 12/14/12 at 7:05 p.m.

The facility's policy, "Death Policy," was reviewed onsite 4/1/13 in the Administrative Conference beginning at 3 p.m. A portion of that policy read in part, "For Autopsy or Medical Examiner Cases and those cases with a potential delay for release that exceeds 3 hours in duration or for which proper preservation of the deceased's body and/or organs require it, the deceased body will be placed in the refrigerated compartment in the morgue."
Another section of that same policy read, "The Nursing Director or designee will notify the pathologist on call that an autopsy has been requested. After hours, the Administrative Coordinator will assume this responsibility."

Employee #3, the Risk Manager, Patient Safety Officer and Continuous Readiness Coordinator commented on 4/1/13 that she did a "Mini Root Cause Analysis," for this complaint shortly after it occurred. The findings of that report revealed that, "The deceased patient was not placed in the refrigerator unit secondary to size/weight and remained autopsy suite. The Pathologist On-Call was not notified as per protocol, of an ordered autopsy or notified that a body was placed in the autopsy suite and not in refrigeration unit due to size. The Nursing Supervisor did not call Pathologist On-Call or communicate during shift change that the Pathologist needed to be notified of an ordered autopsy."

The Nursing Supervisor, employee #11, who was on duty the evening of 12/14/12 was interviewed at 3:30 p.m. on April 1, 2013 in the hospital's Administrative Conference room. Employee #11 stated in that interview that the family was uncertain if they wanted an autopsy done and therefore did not notify the Pathologist On-Call of a possible autopsy.

Employee #7, an RN (Registered Nurse), was interviewed beginning at 9:15 a.m. April 2, 2013 in the conference room. That interview revealed the following information. Employee #7 assisted in the limited post mortem care. Post mortem care is limited when an autopsy is ordered and the need to preserve possible findings on the body is paramount. The patient was taken to the morgue's entrance by two nurses who were met by one of the hospital's security guards. Employee #7 said that the security guard stated that the body would not fit into one of the refrigeration unit's so the body would be placed in the autopsy room and he (the security guard) would drop the temperature.

An interview with the security guard, employee #10, was also conducted on April 2, 2013 in the same conference room; the guard confirmed that he did assist with placing the patient (#3) in the autopsy room. He stated that he placed the body in the autopsy room and turned the thermostat down until it came on. Employee #10 stated that he worked double shifts through the weekend and that the body remained in the autopsy room (not refrigerated) throughout the weekend and reported that to his supervisor on Monday morning when his shift ended.

The autopsy report contained in the patient's record revealed an autopsy was not conducted until 12/17/12 and that the body was in a state of decomposition; the report read in part, "The body has sat at room temperature over the weekend in the morgue."

The body was not released to the funeral home until 12/17/12 at or about 3:05 p.m.