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Based on staff interviews, medical record review, policy and procedure review and during the process of a complaint investigation it was determined the facility failed to clearly define or follow their policy and procedure to obtain permission for an autopsy. No autopsy was performed on Patient #7 as had been ordered by the physician.

The findings were:

Patient #7 died in the facility named in this complaint on December 12, 2010. The physician on duty at the time of the patient's death discussed obtaining an autopsy with Patient #7's family. The family verbally agreed to the autopsy but the autopsy consent was never signed; No autopsy was performed on Patient #7.

The nursing supervisor working when Patient #7 died was interviewed (Nurse #4) on Wednesday Sept 7, 2011. She acknowledged having some recollection of responding to a Rapid Response Team call regarding Patient #7 on the night of December 11, 2011 which led into December 12, 2011. The supervisor described that upon each death, there is a packet of information to be completed; The packet included the autopsy criteria and consent. When asked who's responsibility it was to complete the information within the packet, she acknowledged the process for obtaining consent for autopsy was vague at the time of Patient #7's death however, the process had been reviewed and was currently being finalized. When asked about the autopsy paperwork for Patient #7, the supervisor stated she thought the nurse assigned to Patient #7 at the time of her death (Nurse #5) told her the autopsy consent had not been obtained and she then passed that information to the day shift supervisor (Nurse # 1). The supervisor could not recall whether she made any phone calls related to Patient #7's death such as a call to the funeral home or to the Decedent Affairs at the facility performing autopsies. She acknowledged calls to both places were the responsibility of the nursing supervisor.

The day shift supervisor working on December 12, 2010 (Nurse #1) was interviewed via telephone on September 7, 2011 by the survey team. She recalled receiving the packet of information related to Patient #7's death from night shift supervisor. She stated her normal process was to check the documentation to verify it was complete but acknowledged that on December 12, 2010 she did not check the packet for completion before releasing the body to the funeral home. She stated she could not offer any explanation why she deviated from her normal practice that day.

The hospitalist working when Patient #7 died was interviewed on September 7, 2011. She recalled the night of December 11, 2010 being a busy night with multiple admissions from the ED (Emergency Department). She remembered receiving multiple pages through the shift. The physician acknowledged being present when Patient #7 died and recalled obtaining verbal permission from the family for an autopsy and therefore then wrote an order for an autopsy request. When asked who's responsible for obtaining the autopsy paperwork including the consent, the physician stated the nurses usually fill out the paperwork when a patient dies and then notify the physician if an incomplete item requires the physician's attention.

The survey team interviewed the Vice President of Medical Affairs who stated the autopsy policy and procedure had recently been reviewed and revised. He said some management staff had been reeducated but at the time of this survey, the policy and forms were under review. After investigating why Patient #7's autopsy was not performed, he acknowledged multiple communication lapses within the facility that the soon-to-be revised policy should more clearly define.

Patient #7's medical record was reviewed on both September 7-8, 2011. No evidence of an autopsy consent was found.

The facility's policy titled "Autopsies" that was in effect on December 11, 2010 (revised 5/10) was reviewed on September 9, 2011. The policy stated in part, "Procedure #2. An autopsy permit must be completed. A copy should be placed in the medical record for reference purposes. The original should travel with the deceased to Autopsy Services. #3. The house supervisor should call the Decedent Affairs Office at (receiving hospital with phone number) to notify them of the autopsy." #4 of the same policy stated in part, "If an autopsy request occurs after hours please call Decedent Affairs at (receiving hospital) and inform them of the request and that transportation will be provided at the earliest available time." The policy did not address whether nursing staff or medical staff was responsible for ensuring the autopsy permit (consent) was obtained from the family.

Based on staff interviews, medical record review, and during the process of a complaint investigation it was determined the facility failed to ensure the doctor's order for an autopsy of Patient #7 was carried out.

The findings were:

Patient #7's medical record was reviewed on September 7-8, 2011. The record contained a physician order for an autopsy request dated on December 12, 2010 at 2:40 a.m. No evidence of an autopsy consent was found and the autopsy was therefore not performed.

The nursing supervisor working when Patient #7 died was interviewed (Nurse #4) on Wednesday Sept 7, 2011. She acknowledged having some recollection of responding to a Rapid Response Team call related to Patient #7 on the night of December 11, 2011 which led into December 12, 2011. The supervisor described that upon each death, there is a packet of information to be completed; The packet included the autopsy criteria and consent. When asked who's responsibility it was to complete the information within the packet, she acknowledged the process for obtaining consent for autopsy was vague at the time of Patient #7's death however, the process had been reviewed and was currently being finalized. When asked about the autopsy paperwork for Patient #7, the supervisor stated she thought the nurse assigned to Patient #7 at the time of her death (Nurse #5) told her the autopsy consent had not been obtained and then passed that information to the day shift supervisor (Nurse # 1).

The day shift supervisor working on December 12, 2010 (Nurse #1) was interviewed via telephone on September 7, 2011 by the survey team. She recalled receiving the packet of information related to Patient #7's death from night shift supervisor. She stated her normal process was to check the documentation to verify it was complete but acknowledged that on December 12, 2010 she did not check the packet for completion prior to releasing the body to the funeral home. She stated she could not offer any explanation why she deviated from her normal practice that day.

The survey team interviewed the Vice President of Medical Affairs on September 7, 2011. After investigating why Patient #7's autopsy was not performed, the Vice President acknowledged multiple communication lapses within the facility that the soon-to-be revised policy should more clearly define. He said when the patient's body arrived at the receiving facility for the autopsy without the consent, the autopsy was not performed.