HospitalInspections.org

Based on record review and interview, the facility's Governing Body failed to carry out responsibilities and ensure;

1.) The facility's Regional policy and procedures (P&P) for Death, Autopsy, Post-Mortem Care, and Morgue Management (aka Death Policy) correlated with the facility's form used by Nursing Services titled; Release of Body to Funeral Home & Reportable Death Notification; and

2.) Nursing services implemented the facility's regional policy and procedures regarding Death for Patient #1, however, nursing staff failed to:

A.) Ensure a family member's signature was obtained for the selection of a funeral home on the facility's form titled "Release of Body to Funeral Home & Reportable Death Notification" (aka the Release of Body form), and in accordance with the above Death P&P. The Policy required a "family member signature" on the release of body form with the chosen funeral home, however, the form used by Registered Nurse (RN) A and RN B for Patient #1 dated 07/14 was obsolete, and did not specifically have the word, "signature" resulting in Nursing judgment and inconsistencies whether or not a family member's signature was obtained by hospital staff on the form for the funeral home choice.

As a result of nursing failures and that the facility's Death P&P did not correlate with the facility's release of body form; resulted in allegations by the Next of Kin (NOK)/family member that Patient #1's remains were picked up in error by a funeral home that was not authorized or chosen by the NOK/family member.


B.) Ensure the Death policy and procedures which specified that the deceased body was not to remain on the nursing unit no longer than 2 hours. The deceased body of Patient #1 remained in the Emergency Department (ED) for 8 hours from time of death on 4/13/17 at 18:34 until her remains were picked up from the funeral home representative on 4/14/17 at 02:35; without being sent to the hospital morgue.

This nursing failure resulted in allegations by the NOK/family member that Patient #1's remains were allowed to decompose without rendering the proper preventative post mortem care procedures affecting the outcomes of her funeral services.

Cross Reference to A0386 for specific evidence of findings.



It was determined the cumulative effects of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Governing Body.


Findings included:

1.) A.) Review of the hospital policy entitled, "Regional Death, Autopsy, Post-Mortem Care and Morgue Management," last revision date 03/15 revealed the Office of Primary Responsibility included the Chief Nursing Executive (CNE), the Director of Laboratory Services, Director of Security and Safety, and the Regional Vice President/Chief Administrative Officer. The Policy was approved by the CNE dated 8/21/15. Further review revealed the following:

o PROCEDURES

3. Release of Body - Once a patient has been pronounced, nursing staff must complete the Release of Body to Funeral Home and Reportable Death Notification form (#90343, available in Print Shop) hereafter collectively referred to as the Release of Body Form.

5. Post mortem care - Post mortem care is to be followed as outlined in this Policy utilizing proper authorization forms, including disposition of personal belongings.


10. RELEASE OF BODY

a. If funeral home is known and body can be transported within 2 hours.

i. Obtain name of the funeral home from the responsible person and "obtain family member signature on Release of Body Form."

a) Nursing associate notify funeral home when body is ready for release

b) Body will remain on nursing unit no longer than 2 hours.


b. Funeral home is unknown within 2 hours

i. Post-mortem care completed.

ii. Body is transported to the morgue by nursing and other Associates as needed



B.) Review of the Release of Body and Notification of Death Form #0090343 used for Patient #1 had a revision date of 07/14.

The form contained the following for Patient #1, in part:

o Date of Death: 4-13-17 Time of Death: 1834

o Next of kin notified of death: 1840 By Whom: "At bedside."

I. Release to Funeral Home, Medical Examiner or Family

o Location of Body: Patient Room

o "Words of comfort"/burial materials given to family: Yes

o Disposition of Belongings to (Name/relationship): clothing on Pt. Time/Date: 4/13/17 / 2300

o "Signature of Agent/Family member" receiving belongings (name/relationship): NOK printed in caps (handwritten by RN B and confirmed by RN B during interview.) Signed by RN B. There was not a signature of family member/NOK


Body to be released to:

o Funeral Home (Name): Funeral Home A was written in by RN A (confirmed during interview RN A handwrote funeral home A)

o Funeral Home Address/City, State: 601 N. Center St (written by RN A).

o Name of Funeral Home representative contacted: Funeral Home A representative A handwritten in caps by RN B.

o Family Member consenting to release to Funeral Home: (name/relationship): NOK written in caps and, at "BEDSIDE" (printed By RN B) (This was confirmed by interview with RN B). There was no signature of the family member consenting to release to Funeral Home A.

o Signature of witness (name/title): RN B signed


J. Receipt by Funeral Home or Agent/Family Funeral home notified that body is ready for release:

o Time/Date called: 4/14/17 / 0102 Called by (name/title): RN B's name is written in by RN B.

o Remains received by (name of Funeral Home representative): Funeral Home Representative D's name printed.

o License #: This is blank.

o Released by (Hospital representative name/title): RN B's name is printed in and with RN B's signature.

o Time/Date: 4/14/17 / 0235


C.) The facility's Chief Quality Officer (CQO) / Patient Safety Officer (PSO) was interviewed on 05/22/18 at 10:50 AM and stated the following:

The facility conducts a 100% mortality review by a Peer Review committee. There are two peer review nurses who do initial triage of cases. If there is a potential issue, they work with the Chairman of the Peer Review Committee. The CQO stated the last changes made to the Regional Death, Autopsy, Post-Mortem Care and Morgue Management by the Director of Risk Management (RM) was updated on 03/15 to be in compliance with the changes in CMS regulations related to restraint and reporting. The CQO stated there was a "Forms committee" that reviews forms before changes were made. The Director of Medical Records heads the committee with the Director of RM also a part of that committee. The CQO was asked why the signature line was removed on the release of body form from 11/07 to 07/14; and she indicated that was a question for the Director of RM.


The Peer Review Manager/RN was interviewed on 05/22/18 at 11:30 a.m. and was asked to go through the peer review process. According to her:

They do 100% review on deaths that occur in the hospital - looking for standards of care, quality, following protocols - CPR, stroke, sepsis; and it goes to the physician. She looks to see if the Release of Body Form was completed. She stated that she was the Peer Review nurse that reviewed Patient #1's record for the mortality review and another patient's record (Patient #2) that expired in the emergency department the same night (4/13/17).

She was shown Patient #1's Release of Body Record and asked what they look for during a review. She responded, patient info, autopsy, criteria met for the Medical Examiner (ME), that the ME was notified, making sure police info is filled out, making sure Funeral Home info is filled out. If she notices parts not filled out she follows up with the nurse director on the unit.

She was asked if she saw any concerns with Patient #1's form and responded, "No." She was shown a Release of Body Form used for another patient (Patient #2) death in the ED the same night (4/13/17). She said, "Essentially it's the same form with info in different places." She was asked if she ever looked at the form to see if there were different revised dates on them and responded that she does not. She was asked if she looks to see if a signature is obtained from the family member for the selection of funeral home. She responded, "No."

She was asked if she made sure signatures were done on this particular form for Patient #1. She responded that if she saw anything missing, she would bring it to the attention of the person in charge of the unit. She was asked if she looked to see if a family member signed the form anywhere. She was shown the 2 different forms used on the same night (4/13/17). One form #0090343 (Rev. 11/07) used for Patient #2 included the phrase "Signature of Relative" and was signed by a family member. The other form #0090343 (Rev. 07/14) used for Patient #1 included the phrase, "Family Member consenting to release to Funeral Home: (name/relationship):" Patient #1's form was not signed.

The Peer Review Manager acknowledged that the form for Patient #2 had a signature of a relative and Patient #1's did not. She said she saw a signature of the father receiving the belongings (this was in fact a signature of the RN). She is not responsible for the review of the form itself. She was asked if she would have noted a difference in the form. She said, "It has been picked up on and brought to people's attention." She was asked who it would have been reported to but could not answer. She looks at 300 charts and may not be keeping that close of a look on the revised date of the form. She confirmed the main focus is on the death; expected, unexpected, and if there is a potential clinical issue; and not necessarily the administrative part of the form.

The Peer Review Manager was asked if she ever reviewed how long the body stays in the ED. She responded, that she "may read that in a note." She further stated, the body may stay in the ED an extended period of time related to family request. It depends on the family. It is not an expectation for her to review that. There are not any rules. She was asked if she knows if there is any allotted amount of time a body can stay in the ED without going to the morgue or funeral home and she answered, "No." She does not look at that in her review. She does not look at time of death and when the body was picked up.


The Director of Risk Management (DRM) was interviewed on 05/23/18 at 9:51 AM and stated her responsibilities related to oversight of policies and procedures since 2016. She is responsible for drafting risk management policies and reviewing them. She looks at policies when asked to for compliance with the law. The Director or RM stated she did not write or draft the policy entitled, "Regional Death, Autopsy, Post-Mortem Care and Morgue Management." She does not recall what she may have contributed to this policy. She said she would probably have looked at reportable deaths, fetal demise, restraints and seclusion. During the interview, it was pointed out that the policy says a signature will be obtained by the family member. According to the DRM, she responded, "I did not know that." She confirmed that the policy stated a signature from a family member would be obtained.

The DRM was asked to review the Release of Body Form #0090343 (Rev. 07/14) for Patient #1. She confirmed that there was no signature line or a signature by a family member consenting to release the body to the funeral home listed as Funeral Home A. She reviewed the Release of Body Form #0090343 (Rev. 11/07) for the other Patient; #2 completed on the same date (4/13/17), and confirmed there was a signature line and it was signed by the family member. The Director of RM stated she did not know why a signature line was not there on the form and stated, they did not make sure the policy matched the form with the signature. She stated it was a task force headed by an employee who is no longer at the facility.

Interview on 5/23/18 at 9:51 AM with the RN Program Manager of Policy, Procedure, and Sharepoint stated the following: She nor the DRM knew how the signature line was dropped off of the Release of Body Form. The Program Manager of P&P stated whoever made the changes to the Release of Body Record Form between 2007 and 2013, took that signature line off of the form. "We need to add a signature line."

Cross Reference to A0386 for specific evidence of findings.

Based on record review and interview, the facility failed to ensure organized nursing services were provided in accordance with the patient care needs, and facility policy and procedures affecting 2 of 2 patients reviewed (Patient's #1 and #2).

Specifically, Nursing Services failed to ensure implementation of the facility's regional policy and procedures (P&P) regarding "Death, Post-Mortem Care, and Morgue Management" (aka the Death P&P) for Patient #1. Nursing failures included the following:

1.) Failed to ensure a family member's signature was obtained for the selection of a funeral home on the facility's form titled; "Release of Body to Funeral Home & Reportable Death Notification" (aka the Release of Body form); and in accordance with the above Death P&P. The Policy required a "family member signature" on the release of body form with the chosen funeral home; however the form used by Registered Nurse (RN) A and RN B for Patient #1 dated 07/14 was obsolete, and did not specifically have the word, "signature" resulting in Nursing judgment and inconsistencies whether or not a family member's signature was obtained by hospital staff on the form for the funeral home choice.

As a result of nursing failures and that the facility's Death P&P did not correlate with the facility's release of body form; this resulted in allegations by the Next of Kin (NOK)/family member that Patient #1's remains were picked up in error by a funeral home that was not authorized or chosen by the NOK/family member.


2.) Failed to ensure the Death policy and procedures which specified that the deceased body was not to remain on the nursing unit no longer than 2 hours. The deceased body of Patient #1 remained in the Emergency Department (ED) for 8 hours from time of death on 4/13/17 at 18:34 until her remains were picked up from the funeral home representative on 4/14/17 at 02:35; without being sent to the hospital morgue.

This nursing failure resulted in allegations by the NOK/family member that Patient #1's remains were allowed to decompose without rendering the proper preventative post mortem care procedures affecting the outcomes of her funeral services.


3.) Failed to use current/revised Release of Body to Funeral Home & Reportable Death Notification forms when multiple versions of outdated/obsolete forms were used on 4/13/17 for 2 of 2 Patients (#1, and #2). The facility's Death policy dated 03/15 had the revised form dated 4/15 attached.

a.) On 4/13/17 the Release of Body form used for Patient #1 was dated 07/14 which was not the most revised/current form dated 4/15.

b.) Also, on 4/13/17 another Patient; (#2) expired and the nursing staff used a form dated 11/07; which was not the most revised/current form dated 4/15. However, this release of body form had the word "signature" of relative on the form related to the name of the funeral home to be released to.

These deficient practices resulted in the Condition of Participation for Nursing Services to not be met.

Refer to A0386 for specific evidence of findings.

Based on record review, and interview, the facility failed to ensure organized nursing services were provided in accordance with the patient care needs and facility policy and procedures which affected 2 of 2 patients reviewed (Patient's #1 and #2).

Specifically, Nursing Services failed to ensure implementation of the facility's regional policy and procedures (P&P) last revised, 03/15 regarding "Death, Post-Mortem Care, and Morgue Management" (aka the Death P&P) for Patient #1. Nursing failures included the following:

1.) Failed to ensure a family member's signature was obtained for the selection of a funeral home on the facility's form titled; "Release of Body to Funeral Home & Reportable Death Notification" (aka the Release of Body form); and in accordance with the above Death P&P. The Policy required a "family member signature" on the release of body form with the chosen funeral home; however the form used by Registered Nurse (RN) A and RN B for Patient #1 dated 07/14 was obsolete, and did not specifically have the word, "signature" resulting in Nursing judgment and inconsistencies whether or not a family member's signature was obtained by hospital staff on the form for the funeral home choice.

As a result of nursing failures and that the facility's Death P&P did not correlate with the facility's release of body form; this resulted in allegations by the Next of Kin (NOK)/family member that Patient #1's remains were picked up in error by a funeral home that was not authorized or chosen by the NOK/family member.


2.) Failed to ensure the Death policy and procedures which specified that the deceased body was not to remain on the nursing unit no longer than 2 hours. The deceased body of Patient #1 remained in the Emergency Department (ED) for 8 hours from time of death on 4/13/17 at 18:34 until her remains were picked up from the funeral home representative on 4/14/17 at 02:35; without being sent to the hospital morgue.

This nursing failure resulted in allegations by the NOK/family member that Patient #1's remains were allowed to decompose without rendering the proper preventative post mortem care procedures affecting the outcomes of her funeral services.


3.) Failed to use current/revised Release of Body to Funeral Home & Reportable Death Notification forms when multiple versions of outdated/obsolete forms were used on 4/13/17 for 2 of 2 Patients (#1, and #2). The facility's Death policy dated 03/15 had the revised form dated 4/15 attached. Specifically,

a.) On 4/13/17 the Release of Body form used for Patient #1 was dated 07/14 which was not the most revised/current form dated 4/15.

b.) Also, on 4/13/17 another Patient; (#2) expired and the nursing staff used a form dated 11/07; which was not the most revised/current form dated 4/15. However, this release of body form had the word "signature" of relative on the form related to the name of the funeral home to be released to.



Findings included:


1.) A.) Review of Complainant's (Father and Next Of Kin; NOK to Patient #1) allegations alleged the following from 4/13/17 to 4/14/17:

On 4/13/17 at 5:40 PM Patient #1 arrived to the ED of the hospital with Cardiopulmonary Resuscitation (CPR) in progress. Patient #1 was pronounced deceased at 06:30 PM. Complainant was approached by hospital staff regarding the implementation of the protocol's and processes for expired patients. The Complainant stated the following occurred:

a.) On 4/13/17at 9:00 PM Complainant requested no autopsy; and no tissue/organ donations. Complainant stated he gave immediate permission for embalming but did not want to choose a funeral home/mortuary when initially asked and further indicated he "would go home and decide later at a home setting" after consultation with the family for a funeral home. The Complainant stated he did not like any choices of funeral homes on the "list provided by the [hospital]."

b.) At 10:00 PM Complainant requested for the Primary Care Physician (PCP) of Patient #1 to sign the death certificate.

c.) At 11:00 PM Patient #1 was moved to a "holding room" (from trauma room #8 to room #20); until Patient #1's PCP returned call and confirmed to sign death certificate.

d.) Between 02:30 AM and 02:45 AM (04/14/17), Complainant stated he left the hospital; leaving detailed instructions to the hospital staff at the nursing desk for notification if Patient #1 was moved from room #20. When complainant left the hospital it was his understanding the hospital staff were waiting on a returned call from Patient #1's PCP for confirmation that she would sign the death certificate; and then Patient #1 would then be moved to the hospital's morgue until Complainant and family decided on a chosen funeral home for transfer of Patient #1's remains.


On 4/14/17, after leaving the hospital, the Complainant and family decided on a Funeral Home Mortuary- (B) and he began to call that Funeral Home B at 3:00 AM, 4:00 AM, and 6:00 AM using their 24/7 contact number to request Patient #1's remains be picked up from the hospital. The Complainant was not able to make contact with Funeral Home B's 24/7 contact number due to their voice system not working. Complainant later made contact with Funeral Home B at approximately 09:00 AM and requested their services to pick up Patient #1 from the hospital morgue.

The Complainant stated he also made physical contact with Patient #1's PCP at 08:30 AM on 4/14/17 to inquire about her signing the death certificate. During this contact by the Complainant, the PCP reported to him that hospital staff reported Patient #1 was a hospital admission and was not reported as a death or dead on arrival (DOA).

At 09:00 AM on 4/14/17, Complainant then made phone contact with the hospital ED staff to communicate that Funeral Home B would be coming to pick up Patient #1's remains and that Patient #1's PCP would sign the death certificate. During this call Complainant inquired of the whereabouts of Patient #1 since he did not receive any notifications/phone calls that Patient #1 had been moved from Room #20 to the hospital morgue and only assumed she was still in Room #20. The hospital staff (unknown) he spoke to on the phone could not tell the Complainant at this time of the call where Patient #1's remains where; and confirmed that Patient #1 had not been sent to the hospital morgue; but speculated that she may have been sent to the medical examiner. The Complainant became very upset because he had requested contact before Patient #1 was moved from Room #20 and requested the whereabouts of his daughter/Patient #1. Approximately 30 minutes later after this call the Complainant stated he received a call from hospital staff (unknown) that reported Patient #1's remains had been "errantly released to [Funeral Home Mortuary A] in error by the [Hospital] Emergency Room Staff."

In summary, Complainant alleges; Patient #1 had been released to Funeral Home A without notification to the Complainant/NOK and without authorized consent of the Complainant/NOK for Patient #1 to be released to Funeral Home A. Complainant/NOK stated he never chose Funeral Home A as the funeral home for his daughter and never signed any documentation that designated Funeral Home A as the chosen place for his daughter to be released to. Complainant/NOK later had to sign a release document from Funeral Home A to release Patient #1's remains to Funeral Home B; the Funeral Home of choice.


B.) Record Review of Patient #1's records revealed Hospital Form #0090343, "Release of Body to Funeral Home & Reportable Death Notification," Revised 07/14 for Patient #1 documented the following, in part: RN A and RN B both filled in information on the form as follows.

A. Patient Information

o Date of Death: 4-13-17 Time of Death: 1834

o Pronounced by: ED Physician A

o Doctor who will sign death certificate: ED Physician A written and then errored out with Patient #1's PCP A written in by RN B.

o Next of kin notified of death: 1840 By Whom: "At bedside."


F. Medical Examiner

o Death occurred within 24 hours of admission checked

o Time/Date Medical Examiner or JP notified: 1935 / 4-13-17

o Notified by: Registered Nurse (RN) A

o ME/JP accepted jurisdiction: no

o Case#: 2017-0867

o Release to Funeral Home as Planned (written in with caps by RN B).


G. Police Case Information

o Time/Date Police Dispatcher Notified: 1925 / 4-13-17

o Time/Date Officer arrived: 2152 / 4/13/17

o Officer Name: A Badge #: 1237 Case Number: SAPD 17081588


I. Release to Funeral Home, Medical Examiner or Family

o Location of Body: Patient Room was checked

o "Words of comfort"/burial materials given to family: Yes

o Disposition of Belongings to (Name/relationship): clothing on Pt. Time/Date: 4/13/17 / 2300

o "Signature of Agent/Family member" receiving belongings (name/relationship): NOK printed in caps (handwritten by RN B and confirmed by RN B during interview.) Signed by RN B. There was not a signature of family member/NOK on this form.


Body to be released to:

o Funeral Home (Name): Funeral Home A was written in by RN A (confirmed during interview RN A handwrote funeral home A)

o Funeral Home Address/City, State: 601 N. Center St (written by RN A).

o Name of Funeral Home representative contacted: Funeral Home A representative A handwritten in caps by RN B.

o Family Member consenting to release to Funeral Home: (name/relationship): NOK written in caps and, at "BEDSIDE" (printed by RN B) (This was confirmed by interview with RN B). There was no signature of the family member consenting to release to Funeral Home A.

o Signature of witness (name/title): RN B signed although not witnessing another signature.


J. Receipt by Funeral Home or Agent/Family

Funeral home notified that body is ready for release:

o Time/Date called: 4/14/17 / 0102 Called by (name/title): RN B's name is written in by RN B.

o Remains received by (name of Funeral Home representative): Funeral Home Representative D's name printed.

o License #: This is blank.

o Released by (Hospital representative name/title): RN B's name is printed in and with RN B's signature.

o Time/Date: 4/14/17 / 0235



C.) Review of a one page sheet provided by the ED Manager on 05/10/18 at 2:08 PM and kept in a cabinet in the ED revealed in part:

38 names of funeral homes listed to include addresses and telephone numbers. Funeral Home A and Funeral Home B were both listed on the one page sheet

Further review of Patient #1's medical record revealed it contained this one page sheet with the 38 funeral homes listed and the name of Funeral Home A was highlighted in a blue highlight marker.


D.) Review of the hospital policy entitled, "Regional Death, Autopsy, Post-Mortem Care and Morgue Management," last revision date 03/15 revealed the following in part:

o PROCEDURES

A. PRONOUNCEMENT/NOTIFICATION OF DEATH

1. The patient's attending physician and consulting physician(s) [PCP] are notified immediately of the patient's death. The attending physician is to be asked whether or not he/she will personally pronounce the patient or whether he/she wants nursing to pronounce an adult patient dead ...The attending physician is responsible for signing the death certificate except in cases determined by the Medical Examiner ...

3. Release of Body - Once a patient has been pronounced, nursing staff must complete the Release of Body to Funeral Home and Reportable Death Notification form (#90343, available in Print Shop) hereafter collectively referred to as the Release of Body Form.

5. Post mortem care - Post mortem care is to be followed as outlined in this Policy utilizing proper authorization forms, including disposition of personal belongings.


B. GENERAL POSTMORTEM CARE

2. Throughout the postmortem care, respect for the body is to be maintained.

3. Perform necessary nursing activities to ensure acceptable presentation of the body to the family or significant others.

4. Allow significant time and privacy for family to view the body ...

5. Provide spiritual support to the family/significant other(s).


C. Bexar County - Medical Examiner Required Reporting of Death

a. When a person dies within twenty-four hours after admission to a hospital ...


D. PROCEDURE FOR REPORTABLE DEATHS

1. ...a. Notify the San Antonio Police Department (SAPD) at 210.207.7273.

b. SAPD will assign a case number to be documented on the Release of Body Form

c. Notify Bexar County Medical Examiner's Office at 210.335.4011; The Medical Examiner Investigator will determine if the body needs to be sent to the Medical Examiner's Office.

d. The Medical Examiner Investigator's badge number and name shall be recorded on the Release of Body Form.


8. DEATH CERTIFICATE

a. If the Medical Examiner/Justice of the Peace does not take jurisdiction of a body the attending physician is responsible for signing the death certificate.

b. The electronic death certificate should be signed within 5 days after receipt and filed within 10 days.


10. RELEASE OF BODY

a. If funeral home is known and body can be transported within 2 hours

i. Obtain name of the funeral home from the responsible person and "obtain family member signature on Release of Body Form."

a) Nursing associate notify funeral home when body is ready for release

"b) Body will remain on nursing unit no longer than 2 hours."


b. Funeral home is unknown within 2 hours

i. Post-mortem care completed.

ii. Body is transported to the morgue by nursing and other Associates as needed


ATTACHMENTS

....Release of Body and Notification of Death Form #0090343 (Rev. 04/15)


E.) Review of Time Sheet Records for 4/13/17 and 4/14/17 for RN A and RN B revealed the following:

RN A worked 4/13/17 from 06:48 AM to 08:01 PM.

RN B worked 4/13/17 from 05:40 PM to 07:28 AM on 4/14/17.


F.) During an interview with RN A on 5/14/18 at 2:25 PM and again on 05/22/18 at 9:10 AM confirmed the above Body Release record for Patient #1. RN A stated he wrote in the name of the Funeral Home A in the area titled: Body Released to Funeral Home Name, Funeral Home Address/City, State, Phone #; was filled in and completed by him. RN A confirmed he did not have NOK/family member sign the area that indicated; "Family Member consenting to release to Funeral Home." RN A was asked where he received the information that Funeral Home A was the selected Funeral Home for Patient #1 and he responded the one sheet funeral home list shown to him was the one given to the family. RN A indicated, "If you don't already have the name of a funeral home, this is a list of funeral homes and if the one you want is not on the list, I will look up the address and phone number for them." RN A stated either the family circles or highlights the funeral home they want or based on what they tell him. RN A stated he did not assist the family with the choice of funeral home from the list. He was at the desk with other paperwork when the "chaplain" came back with the list and informed him that Funeral Home A was the family's choice. RN A indicated he was pretty sure it was a hospital chaplain but does not recognize all the chaplains since he had just started orientation on March 20th in the ED and April 12th was the first day in the ED after orientation. RN A stated he presumed the information he was given was accurate and did not ask or verify with the family member/NOK that Funeral Home A was the choice selected.

During an interview with the Hospital's Chaplain A on 5/14/18 at 04:25 PM stated he remembered Patient #1's father/NOK and made contact with him shortly after the death of Patient #1. When the Chaplain A arrived to the ED the father/NOK was there by himself and before his "own chaplain" arrived to the ED. The Chaplain A stated he gave Patient #1's father the "words of comfort" booklet. Chaplain A was asked if he presented a list of funeral homes to Patient #1's father, and he responded; "no, did not give him a list of funeral homes; only gave him words of comfort" which has addresses of funeral homes within the booklet. The Chaplain stated that the father did not pay any attention to the booklet, but took it and said thank you. The father's own chaplain came into the room and then the Hospital Chaplain A stated he stepped outside of the room. The father's "military chaplain stayed with him" and the hospital chaplain left when he was not needed anymore. The hospital Chaplain A was asked again if he ever gave Patient #1's father a one page list with funeral homes listed and he responded again, "no, don't hand that out, just a booklet." The hospital Chaplain stated he was not aware of the list kept in the ED, don't pay attention to that, just carry a booklet that has a list of funeral homes in the booklet.


During an interview with the ED RN B on 05/14/18 at 3:15 PM stated the following:

Patient #1 was in bed #8 [trauma] when he came on duty; and there were a few family members in room. RN B received report from RN A that Code was over and pronouncement of death was done. RN A gave him the release of body form that was incomplete. His goal was to fill out the form (release of body); had many missing blanks, either put n/a or fill in; it "all needs to be completed." RN B stated he filled in with the clothing info and details completed. RN B stated that RN A had already filled out some of the areas on the form; and saw that he already had a funeral home (A) listed on the form. RN B was asked who wrote the name of the funeral home on the form and he responded RN A. He said he had "no idea how the family selected the funeral home [A]" it was already highlighted on the phone sheet-adjunct to the booklet (the one page list of funeral homes). The Funeral home list in Patient #1's record was "highlighted" with Funeral Home A. RN B stated the family is provided the form and they picked the facility. RN B confirmed that was his writing where it stated, "Signature of Agent/Family member receiving belongings (name/relationship)" and handwritten was the father of Patient #1 in caps and the signature of RN B. RN B was asked if the family ever signed the form with the chosen funeral home and he responded, "If I am the nurse that initiates the form-will have the family sign the form; try to get them to, will have them sign form." "Don't hunt down or ensure they sign." The family's chaplain was "working hard to keep the father calm" so RN B stated he "printed in [Patient #1's father's name] @ bedside; he was grief stricken."


During a phone interview with Patient #1's father/complainant on 5/21/18 at 12:30 PM, stated the following:

He never gave the hospital permission to transfer his daughter anywhere to any Funeral Home. He stated there was a checklist going around with funeral homes listed but he wanted to go home and inform his wife; when he left hospital stated he would get back with the hospital on a funeral home selection. He left the hospital around 02:30 AM on 4/14/17. Arrived home around 02:45 AM. He stated he found out on the 14th (April, 2017) at 12:00 PM that his daughter was "shipped to a funeral home did not choose." He indicated that he did not receive any phone calls from the hospital that his daughter was picked up by a funeral home. He stated the funeral homes listed were on a pre-typed sheet - he did not select any of them; and did not remember seeing Funeral Home B listed on the list he saw. The complainant indicated the Hospital chaplain came and provided "standard paperwork" within 2 hours and he had a prayer with him. The Complainant stated before he left hospital at 02:30 AM he and his own chaplain stopped by the nurses desk and verbally told them if Patient #1 was moved anywhere from room #20 (i.e., morgue, ME or from room) wanted to be called. Left personal contact information. The Complainant stated that Patient #1 should have been sent to the morgue until the family selected a funeral home. Complainant stated he was asked about 08:00 PM on 4/13/17 for embalming permission and he was asked a series of questions and that he consented to embalming because the "quicker; more can preserve natural appearance; timelines were broke, and [Patient #1] was left disfigured."


2.) The Complainant requested an accountability record specifically of post mortem care; "morgue storage" and every movement of Patient #1's remains while at the facility. Complainant asks why Patient #1's remains were allowed to stay in Room #20 for those extended hours without proper post mortem care.

Review of Patient #1's medical record documented the time of death on 4/13/17 at 18:34; and the time her remains were picked up from the funeral home representative on 4/14/17 at 02:35 (8 hours, 1 minute).

Review of the hospital policy entitled, "Regional Death, Autopsy, Post-Mortem Care and Morgue Management," last revision date 03/15 revealed on page 11 of 29; "b) Body will remain on nursing unit no longer than 2 hours." On page 12 of 29 indicated if Funeral home is unknown within 2 hours, "i. Post-mortem care completed. Ii. Body is transported to the morgue by nursing and other Associates as need."

Review of the Pathology Laboratory Morgue Log revealed there were 9 deaths documented in the log from 04/05/17 to 04/28/17 and Patient #1 was not on the hospital morgue log.


During an interview with the RN Director of ED on 05/14/18 at 1:50 PM was asked how long a deceased body could remain in the ED and he stated an appropriate amount of time could be up to "4 hours before morgue the body. Four hours max-then move to morgue; no more than 4 hours." The Director of ED stated he did not know the policy was at 2 hours; until he just read the policy during this interview and confirmed according to the Death policy, a deceased body can remain in the ED for "2 hours from the time of death." The Director of ED stated exceptions could be made up to the charge nurse and judgment based on circumstances. The Director of ED confirmed after review of Patient #1's record that the time of death until body was released for pick up by funeral home was 8 hours. The Director of ED confirmed that Patient #1's body was not sent to the hospital morgue and stated she remained in the ED "twice as long" as she should have been, and could have been due to "family dynamics and flow in the department."


During an interview with RN A on 5/14/18 at 2:25 PM was asked how long a deceased patient was allotted to occupy a bed in the ED. RN A responded 2 hours was the allotment for a body to remain in the ED; if the family wants to stick around, but then the deceased patient was sent to the hospital morgue. RN A stated that if the family was present, we "don't send to the morgue." If the family all have left and gone home with no one present; and the facility staff were done with notifications; then an hour or 2 is allotted after notification to the funeral home before the body is transferred to the morgue.


During an interview with RN B on 05/14/18 at 3:15 PM was asked how long a deceased body/patient can stay in the ED once expired and he stated it depended on the circumstances; "like to get out in a couple of hours. The funeral home has 1 hour to pick up after they are called." RN B stated the longest time frame that he has seen a body stay in the ED once expired was "5 hours." RN B stated that may be breaking the policy if allow the requests of family.


During an interview with ED Charge Nurse/RN B on 5/23/18 at 12:00 PM was asked how long a deceased body can stay in the ED once expired and she stated "around 2 hours; can't just hold the body there waiting on family from long distances otherwise decomposing begins." Charge Nurse RN B indicated once the funeral home was notified; and if they cannot come within the hour, then will communicate and transfer the body to the hospital morgue.


3.) a.) On 4/13/17 the Release of Body form used for Patient #1 was dated 07/14 which was not the most current revised/current form dated 4/15.

b.) Also, on 4/13/17 another Patient; (#2) expired and the nursing staff used a form dated 11/07; which was not the most current/revised form dated 4/15.


During an interview with the Director of Risk Management (DRM) on 05/23/18 at 9:51 AM confirmed the last changes made to the hospital policy entitled, "Regional Death, Autopsy, Post-Mortem Care and Morgue Management" with the last revision date listed as "03/15" and a Release of Body to Funeral Home & Reportable Death Notification "Form #0090343 (Rev. 04/15)" were the most current forms when Patient #1 expired on 4/13/17. The DRM also confirmed the forms used by nursing staff for Patient #1 and Patient #2 on 4/13/17 were not the most current release of body form in circulation on that date.