HospitalInspections.org

Bringing transparency to federal inspections

4605 MACCORKLE AVENUE SW

SOUTH CHARLESTON, WV 25309

PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING

Tag No.: A0130

Based on record review, policy review and staff interviews it was determined the Nursing Supervisor failed to follow the patient's plan of care and the next of kin's final wishes that upon death, her husband's body was to be transported to Freeman's Funeral Home, in one (1) of thirty (30) medical records reviewed (patient #1).

1. Review of the medical record for patient #1 revealed a determination of capacity on 04/01/19 with a decision of lacks capacity and was signed by physician #3 and the patient's wife. The patient's wife was to make all medical decisions due to the lack of capacity for the patient. The patient expired on 04/02/19 at 1:23 a.m. A body release form was completed by Registered Nurse (RN) #1 on 04/02/19 at 1:58 a.m. that states in part: "Body Released to: Freeman Funeral Home, Chapmanville, WV. Next of Kin: (States patient's spouses name and phone number). Next of Kin relationship: Spouse/Significant Other. Autopsy: No." Further review of the death certificate completed by physician #1 revealed cause of death was aspiration pneumonia and autopsy was marked no. It should be noted a copy of the death certificate was requested numerous times throughout the survey and no copy of the death certificate was given to this surveyor upon exit.

2. Review of the policy titled Patient Rights & Responsibilities with an effective date of 08/2017 states in part: "Have a designated representative make health care decisions for you in the event that you cannot."

3. An interview was conducted with RN #1 on 04/08/19 at 11:39 a.m. When asked if she remembered patient #1 and if so, explain the spouse's wishes upon death for the patient she stated in part: "I remember him. After the pastor prayed with the patient and family, I asked the wife if she knew what funeral home she wished for the patient to be taken to. She gave me a funeral home in Chapmanville and I remember she didn't hesitate. She even gave me the address and phone number and what the funeral home was called." When asked how soon the wife left the hospital after the decision was made for the patient to be transported to the funeral home she stated in part: "About five minutes later almost everyone left except a few family members that stayed for about fifteen more minutes." When asked if the wife had requested an autopsy on the patient she stated in part: "No, there was no mention of an autopsy and she was very clear about what funeral home to send him to." When asked if she later learned about the patient being sent for an autopsy she stated in part: "I can't remember if the Nursing Supervisor told me or the Charge Nurse but about thirty or forty minutes after the wife, son and daughter left, we were told to hold the patient and to call the funeral home to cancel them, that the daughter had came to the supervisor's office and requested an autopsy." When asked if she made a note in the patient's chart to change the body release form she stated in part: "No, I thought the supervisor would." When asked if the physician was made aware that the patient was being held for an autopsy she stated in part, "I didn't tell him so I don't know."

4. A telephone interview was conducted on 04/08/19 at 1:49 p.m. with Nursing Supervisor #1. When asked if he remembered the patient and how he became involved in the patient's change from going to a funeral home to an autopsy, he stated in part: "Well, I was in my office and a woman and a man showed up and asked for an autopsy. The woman was the patient's daughter. I've never had anyone show up in my office and ask those questions but I gave them the information they requested and the number to call in the morning to request an autopsy. They read the information and I told them they normally request the money up front before accepting the patient and she told me that wouldn't be a problem. They wanted an autopsy to see if the father had black lung. So after they left I called up to the floor and told the nurse to call the funeral home for a hold on picking up the patient because the daughter wanted an autopsy." When asked if he had contacted the wife to see if she wanted an autopsy he stated, "No, I didn't. I gave them the information and requested a hold on the body." When asked if he documented a change in the medical record to show the patient would remain in the morgue and not be going to the funeral home he stated in part: "No, I didn't but I passed the information along in report about the patient going for an autopsy instead of to the funeral home and that the family should come in this morning." When asked if he changed the patient's disposition on the death log he stated in part: "No, I thought the dayshift supervisor would when the patient left for an autopsy."

5. An interview was conducted with the Interim Director of Nursing immediately following the telephone interview with Nursing Supervisor #1. When asked if the expectation that documentation of the change in disposition should have occurred she stated, "Yes, they should have documented it in the medical record and the death log. We will also add an area on the death log for this in the future."

6. An interview was conducted with the Director of Quality on 04/08/19 at 8:50 a.m. His expectation was the wife should have been called to request permission for the autopsy.

PATIENT RIGHTS: INFORMED CONSENT

Tag No.: A0131

Based on record review, policy review and staff interviews it was determined the hospital failed to obtain an informed consent for an autopsy from the next of kin in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential for all patients who wish to be taken to a funeral home to be given an autopsy without proper legal consent.

1. Review of the medical record for patient #1 revealed a determination of capacity on 04/01/19 with a decision of lacks capacity and was signed by physician #3 and the patient's wife. The patient's wife was now to make all medical decisions due to the lack of capacity for the patient. The patient expired on 04/02/19 at 1:23 a.m. A body release form was completed by Registered Nurse (RN) #1 on 04/02/19 at 1:58 a.m. that states in part: "Body Released to: Freeman Funeral Home, Chapmanville, WV. Next of Kin: (States patient's spouses name and phone number). Next of Kin relationship: Spouse/Significant Other. Autopsy: No. Further review of the death certificate completed by physician #1 revealed cause of death was aspiration pneumonia and autopsy was marked no. It should be noted a copy of the death certificate was requested numerous times throughout the survey and no copy of the death certificate was given to this surveyor upon exit. Further review of the medical record revealed a consent for autopsy, with the consent marked for a child over the age of eighteen, completed by telephone and signed by someone other than the next of kin. The consent for autopsy states in part: "2. Surviving spouse of the deceased (if there is no medical power of attorney representative (N.B. common law marriage are not recognized in West Virginia and spouse is considered next of kin even after protracted legal separation. 3. Child of the deceased over the age of 18 if there is no medical power of attorney or surviving spouse, however the child's permission shall not be valid if another child of the deceased over the age of 18 objects prior to said autopsy." Under the contact information in the electronic medical record it lists the next of kin as the patient's wife and states her name. No other contact information for any other person is listed.

2. Review of the policy titled Immediate Post Mortem Care with a last review date of 11/2016 states in part: "Determination of an autopsy will be made by the physician and/or family." (Reference policy Autopsy).

3. Review of the policy titled Autopsy with an effective date of 09/2016 states in part: "Consent for autopsies must be obtained using the regular request and consent for autopsy form and signed by the responsible family members. In general the following order of priority is legally mandated. A. Spouse. B. Children over (18). C. Parents. D. Fiduciary of Estate. E. Person legally handling affairs. In general...A properly authorized autopsy request relies on consent from the responsible person with the lowest number (highest precedence)."

4. A telephone interview was conducted with physician #1 on 04/07/19 at 12:19 p.m. When asked if he remembered patient #1, discussed an autopsy with the family or if he felt the need for an autopsy on the patient and if so, to explain the need, he stated in part: "I do remember the patient. He was a very critical patient and we did not expect for him to survive and we talked to the family numerous times that night. The wife wanted the patient to go to a nursing home and that is what was completed. I did not feel a need for an autopsy. The expectation was that he was critical and no matter how much we adjusted ventilation settings, he was getting worse and we talked with the family numerous times during the night about how critical he was." When asked if he marked no autopsy on the death certificate he stated in part: "Yes, the patient was not to get an autopsy and at the time I filled out the death certificate I did not know he was getting an autopsy."

5. An interview was conducted on 05/07/19 at 2:51 p.m. with the hospital's general counsel. When asked how the consent was obtained for the autopsy for patient #1, who signed the consent for autopsy and if he documented in the medical record for a change in disposition he stated in part: "I of course was notified of the patient's death and that the daughter wanted an autopsy and I wanted an autopsy, so I contacted her the next morning and we arranged to meet here. She came in and we discussed the autopsy and she wasn't able to pay for it and since I wanted one we agreed we would pay for it and the consent was signed by the daughter and witnessed." When asked if the wife was with the daughter he stated in part: "No, she wasn't. She was home in bed distraught over the death and the family requested she not be contacted." When asked if the wife was contacted for her consent as the next of kin for permission to complete the autopsy he stated in part: "No, she was at home in bed and the family didn't want her bothered." When asked if he documented the patient's change in disposition in the medical record or the conversation with the daughter he stated in part: "No I did not." When asked for clarification of the meeting occurring in the hospital or by telephone he stated, "It occurred in my office." When asked why the consent was marked that it occurred by telephone he stated in part: "The consent is a little confusing and the witness must have marked it." During the interview he concurred that the wife should have been the one to sign the consent but he was respecting the daughters wishes.

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on record review and staff interviews it was determined the Hospital Supervisor failed to ensure that one (1) of thirty (30) death records reviewed (patient #1) had an accurate disposition of the patient listed in the medical record and the death log. This failure has the potential for all patients who expire in the hospital to not have their or their representatives final wishes to be respected.

1. Review of the medical record for patient #1 revealed a determination of capacity on 04/01/19 with a decision of lacks capacity and was signed by physician #3 and the patient's wife. The patient's wife was now to make all medical decisions due to the lack of capacity for the patient. The patient expired on 04/02/19 at 1:23 a.m. A body release form was completed by Registered Nurse (RN) #1 on 04/02/19 at 1:58 a.m. that states in part: "Body Released to: Freeman Funeral Home, Chapmanville, WV. Next of Kin: (States patient's spouses name and phone number). Next of Kin relationship: Spouse/Significant Other. Autopsy: No. Further review of the death certificate completed by physician #1 revealed cause of death was aspiration pneumonia and autopsy was marked NO. It should be noted a copy of the death certificate was requested numerous times throughout the survey and no copy of the death certificate was given to this surveyor upon exit.

2. An interview was conducted with RN #1 on 04/08/19 at 11:39 a.m. When asked if she remembered patient #1 and if so, explain the spouse's wishes upon death for the patient, she stated in part: "I remember him. After the pastor prayed with the patient and family, I asked the wife if she knew what funeral home she wished for the patient to be taken to. She gave me a funeral home in Chapmanville and I remember she didn't hesitate. She even gave me the address and phone number and what the funeral home was called." When asked how soon the wife left the hospital after the decision was made for the patient to be transported to the funeral home she stated in part: "About five minutes later, almost everyone left except a few family members that stayed for about fifteen more minutes." When asked if the wife had requested an autopsy on the patient she stated in part: "No, there was no mention of an autopsy and she was very clear about what funeral home to send him to." When asked if she later learned about the patient being sent for an autopsy she stated in part: "I can't remember if the Nursing Supervisor told me or the Charge Nurse but about thirty or forty minutes after the wife, son and daughter left we were told to hold the patient and to call the funeral home to cancel them, that the daughter had came to the supervisor's office and requested an autopsy." When asked if she made a note in the patients chart to change the body release form she stated in part: "No, I thought the supervisor would." When asked if the physician was made aware that the patient was being held for an autopsy she stated in part: "I didn't tell him so I don't know.

3. A telephone interview was conducted on 04/08/19 at 1:49 p.m. with Nursing Supervisor #1. When asked if he remembered the patient and how he became involved in the patients change from going to a funeral home to an autopsy, he stated in part: "Well, I was in my office and a woman and a man showed up and asked for an autopsy. The woman was the patient's daughter. I've never had anyone show up in my office and ask those questions but I gave them the information they requested and the number to call in the morning to request an autopsy. They read the information and I told them they normally request the money up front before accepting the patient and she told me that wouldn't be a problem. They wanted an autopsy to see if the father had black lung. So after they left I called up to the floor and told the nurse to call the funeral home for a hold on picking up the patient because the daughter wanted an autopsy." When asked if he had contacted the wife to see if she wanted an autopsy he stated, "No, I didn't. I gave them the information and requested a hold on the body." When asked if he documented a change in the medical record to show the patient would remain in the morgue and not be going to the funeral home he stated in part: "No, I didn't but I passed the information along in report about the patient going for an autopsy instead of to the funeral home and that the family should come in this morning. When asked if he changed the patient's disposition on the death log he stated in part: "No, I thought the dayshift supervisor would when the patient left for an autopsy."

4. An interview was conducted with the Interim Director of Nursing immediately following the telephone interview with Nursing Supervisor #1. When asked if the expectation that documentation of the change in disposition should have occurred she stated, "Yes, they should have documented it in the medical record and the death log. We will also add an area on the death log for this in the future."

5. An interview was conducted with the Director of Quality on 04/08/19 at 8:50 a.m. and his expectation is that the medical record would be accurate.

FORM AND RETENTION OF RECORDS

Tag No.: A0438

Based on record review and staff interviews it was determined the hospital failed to ensure the medical record disposition (where the patient's body is sent) upon death is accurate in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential for all patient's medical records to contain false information on where the patient's body was transported upon death.

1. Review of the medical record for patient #1 revealed a determination of capacity on 04/01/19 with a decision of lacks capacity and was signed by physician #3 and the patient's wife. The patient's wife was to make all medical decisions due to the lack of capacity for the patient. The patient expired on 04/02/19 at 1:23 a.m. A body release form was completed by Registered Nurse (RN) #1 on 04/02/19 at 1:58 a.m. that states in part: "Body Released to: Freeman Funeral Home, Chapmanville, WV. Next of Kin: (States patient's spouses name and phone number). Next of Kin relationship: Spouse/Significant Other. Autopsy: No. Further review of the death certificate completed by physician #1 revealed cause of death was aspiration pneumonia and autopsy was marked no. It should be noted a copy of the death certificate was requested numerous times throughout the survey and no copy of the death certificate was given to this surveyor upon exit.

2. An interview was conducted with RN #1 on 04/08/19 at 11:39 a.m. When asked if she remembered patient #1 and if so, explain the spouse's wishes upon death for the patient. She stated in part: "I remember him. After the pastor prayed with the patient and family I asked the wife if she knew what funeral home she wished for the patient to be taken to. She gave me a funeral home in Chapmanville and I remember she didn't hesitate. She even gave me the address and phone number and what the funeral home was called." When asked how soon the wife left the hospital after the decision was made for the patient to be transported to the funeral home she stated in part: "About five minutes later almost everyone left except a few family members that stayed for about fifteen more minutes." When asked if the wife had requested an autopsy on the patient she stated in part, "No, there was no mention of an autopsy and she was very clear about what funeral home to send him too." When asked if she later learned about the patient being sent for an autopsy she stated in part: "I can't remember if the Nursing Supervisor told me or the Charge Nurse but about thirty or forty minutes after the wife, son and daughter left, we were told to hold the patient and to call the funeral home to cancel them, that the daughter had came to the supervisor's office and requested an autopsy." When asked if she made a note in the patient's chart to change the body release form she stated in part: "No, I thought the supervisor would." When asked if the physician was made aware that the patient was being being held for an autopsy she stated in part: "I didn't tell him so I don't know.

3. A telephone interview was conducted on 04/08/19 at 1:49 p.m. with Nursing Supervisor #1. When asked if he remembered the patient and how he became involved in the patient's change from going to a funeral home to an autopsy he stated in part: "Well, I was in my office and a woman and a man showed up and asked for an autopsy. The woman was the patient's daughter. I've never had anyone show up in my office and ask those questions but I gave them the information they requested and the number to call in the morning to request an autopsy. They read the information and I told them they normally request the money up front before accepting the patient and she told me that wouldn't be a problem. They wanted an autopsy to see if the father had black lung. So after they left I called up to the floor and told the nurse to call the funeral home for a hold on picking up the patient because the daughter wanted an autopsy." When asked if he had contacted the wife to see if she wanted an autopsy he stated, "No, I didn't. I gave them the information and requested a hold on the body." When asked if he documented a change in the medical record to show the patient would remain in the morgue and not be going to the funeral home he stated in part: "No, I didn't but I passed the information along in report about the patient going for an autopsy instead of to the funeral home and that the family should come in this morning." When asked if he changed the patient's disposition on the death log he stated in part: "No, I thought the dayshift supervisor would when the patient left for an autopsy."

4. An interview was conducted with the Interim Director of Nursing immediately following the telephone interview with Nursing Supervisor #1. When asked if the expectation that documentation of the change in disposition should have occurred she stated, "Yes, they should have documented it in the medical record and the death log. We will also add an area on the death log for this in the future."

5. An interview was conducted with the Director of Quality on 04/08/19 at 8:50 a.m. and his expectation is that the medical record would be accurate.



38861

Based on document review and staff interviews it was revealed the facility failed to ensure correct medical information was retained in each medical record. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #8). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #8 was completed on 5/7/19. The medical record contained a photo copy of a do not resuscitate (DNR) order for another patient. Further review revealed a DNR order for patient #8. Patient #8 passed away on 3/30/19.

2. A review of the policy titled Legal Medical Record Definition, effective date 11/2015, stated in part: "Each medical record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results and promote continuity of care among health care providers."

2. An interview was conducted with the Director of Quality on 5/8/19 at 2:39 p.m. He concurred another patient's DNR order was in the medical record of patient #8.