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JAVON BEA HOSPITAL
MEDICAL STAFF - ACCOUNTABILITY
Tag No.: A0049
Based on document review and staff interview, it was determined for 3 of 5 (Pt. #s 1, 6 and 8) clinical records reviewed, the hospital failed to ensure a physician pronounced the death of a patient.
Findings include:
1. Hospital policy titled, "Pronouncement of Death (reviewed 12/11)" stated in part, "It is the policy of Rockford Memorial Hospital that only a physician licensed in the State of Illinois who is a member of the Medical Staff of RMH will pronounce a patient dead."
2. The clinical record of Pt. #1 was reviewed on 8/19/13. Pt. #1 was an 86 year old female admitted on 10/10/12 with the diagnoses of respiratory distress, chronic obstructive pulmonary disease and dementia. A progress note written by a RN dated 10/22/12 at 9:00 AM included, " Pt. expired. No heart tones. No respirations. Dr. Brefeld notified. " The clinical record lacked documentation of a physician pronouncing death.
3. The clinical record of Pt. #6 was reviewed on 8/21/13. Pt. #6 was a 56 year old male admitted on 6/13/13 with the diagnosis of end stage renal disease. The Post Mortem flowsheet dated 6/16/13 included that Pt. #6 expired at 12:20 PM and was pronounced by a nurse with a second nurse witnessing the death. The clinical record lacked documentation of a physician pronouncing death.
4. The clinical record of Pt. #8 was reviewed on 8/21/13. Pt. #8 was a 60 year old female admitted on 7/24/13 with the diagnosis of cellulitis and gangrene of the right foot. The Post Mortem flowsheet dated 7/29/13 included that Pt. #8 expired at 10:40 PM and was pronounced by a nurse with a second nurse witnessing the death. The clinical record lacked documentation of a physician pronouncing death.
5. The Medical Director for the Hospitalists (E#8) was interviewed on 8/22/13 at 10:40 AM. When asked about the death pronouncing process in the hospital, E#8 stated, " it is hospital policy to have a physician pronounce the death of a patient. The physician should physically see the patient and pronounce the patient themselves. "