HospitalInspections.org

Based on interviews, medical record and facility documents review, the facility staff failed to protect patient's right to have a death certificate signed within the timeframe defined in the facility's policy.

The findings included:

On 10/19/22 at 8:49 a.m., the complainant emailed a copy of the death certificate to the surveyor. The surveyor confirmed that the death certificate was signed was on 7/28/22 by Staff Member #14 (S14). Patient #1 (P1) died on 7/10/22 as indicated in the complaint.

On 10/18/22 at 11:15 a.m. an interview was conducted with Staff Member #7 (S7). S7 was asked about the process and paperwork to be completed after a patient expires in the hospital. S7 explained that physicians are set up with access to the Electronic Death Registration System (EDRS). When a patient expires, the attending physician will receive a notification, either by text or email that a death certificate is ready to be signed. The physician has to log in and sign the certificate within a 24 hour period. Sometimes a physician may not be able to sign it within that time frame due to their work schedule. S7 stated that death certificates that are needed for cremation of a body need to be signed with urgency. S7 stated that it is not usually an issue for a physician to sign it in a timely manner thanks to the notifications.

On 10/18/22 at 1:10 p.m. an interview was conducted with Staff Member #8 (S8). S8 explained that they check the EDRS system everyday, excluding weekends, to make sure that physicians are signing the death certificates when they are available in the system. S8 further explained that they send reminders to a physician if the document is not signed or have another physician who cared for patient sign the death certificate. S8 stated that usually physicians have good turnaround times in signing. If the physician is not available, S8 finds another physician to take care of it. S8 ensured the surveyor they keep up with the EDRS to make sure the death certificates are signed and communicate with funeral homes to request the funeral home to reassign it to another physician if needed. S8 explained that physicians have a 24 hours to sign the death certificates. S8 was asked if (they) keep a log or have a tracking method to make sure death certificates are signed within this 24 hour period, S8 replied that they do not keep a log because the checks of the EDRS are regular. S8 was asked if there had been any incidents where the death certificate were not signed within a 24 hour period. S8 replied that it may have happened before but that they are good about checking the EDRS. The only tracking method that S8 keeps is "a log sent to Richmond of all the death's that have occurred". S8 was asked if all the physician's in the hospital have access to the EDRS, they clarified that usually physicians that work at night do not have access. S8 is who sets up access for new physicians in the EDRS system when they start employment with the hospital.

On 10/19/22 at 11:03 a.m., S8 provided a log from the EDRS system for P1's death certificate. It revealed that the record was created by the funeral home on 7/13/22. On 7/18/22, it was assigned a doctor who did not treat P1 while in the hospital. That entry was deactivated. On 7/19/22, it was assigned to S14, and was deactivated. The record was instead assigned to S11 on 7/19/22 and was deactivated. On 7/27/22 it was assigned to another physician who did not treat P1 while in the hospital and again deactivated. On 7/27/22 it was assigned to S14 and was signed by S14 on 7/28/22. S8 explained that when entries are assigned to doctor who did not treat a deceased patient, the physician will reject the entry and it gets sent back to the funeral home. S14 stated in an interview on 10/19/22 that they were not aware this happened. S14 stated that usually the funeral home will contact the hospital to determine which physician should sign a death certificate. S14 stated that this funeral home never contacted the hospital to inquire on who was the correct physician to assign P1's certificate to. S14 also added that S11 is not entered into the EDRS because (they) work at nights and night physician's usually do not sign death certificates.

In an interview with S11 on 10/19/22 at 9:34 a.m., S11 stated that (they) do not have access to the EDRS. S11 explained they were covering a night shift that evening at the hospital and do not usually work the night shift.

An interview was conducted with S14 on 10/19/22 at 12:30 p.m.. S14 did not recall signing this death certificate or that there was a delay. S14 explained that when they receive the notification to sign a death certificate that they go into the EDRS and complete it. When asked why S14 did not sign the death certificate when assigned to them on 7/19/22, S14 stated that they may have thought that it was not their patient and mistakenly reassigned it to S11. S14 stated that they understood that there is an urgency to getting these death certificates signed and agreed that improvements can be made so that this does not reoccur.

A review of the Death Record and Release of Body Authorization document was conducted. This form accompanies the deceased body to the funeral home. It lists the date of death as 7/10/22 at 2:46 a.m. and the names of S14 and S11 as physicians. The body was released to the funeral home at 7:56 a.m. on 7/10/22.

A review of the facility's policy "Death Pronouncement-Virginia-Ballad Health" stated "E. The medical certification section for a death certificate shall be completed and filed electronically with the State Registrar of Vital Records using the Electronic Death Registration System within twenty-four (24) hours after death by the physician in charge of the patient's care for the illness or condition which resulted in death except when the case resulted in inquiry or investigation by the Office of the Chief Medical Examiner, or by the physician that pronounces death".

On 10/18/22, a review of the spreadsheet that S8 "sends to Richmond" revealed that the hospital tracks the name of the deceased, the medical record number, the death date, date of birth, age, attending physician, discharge disposition, unit, primary diagnosis and admitting diagnosis. It did not track the date that the death certificate was signed or assigned to physician for completion.

The findings were discussed with Staff Members #4 and 6 during the survey and again at the time of exit conference on 10/19/22.