HospitalInspections.org

Based on document review and interview, it was determined that for 9 of 18 (Pts #14 - #22) patients who had autopsies between 4/1/19 and 7/1/19 and were involved in a security breach, the Hospital failed to ensure that the autopsy photographs were saved to the patients' medical records to ensure the medical records were complete.

Findings include:

1. The Hospital's policy titled, "Autopsy Photography" (approved 8/5/19) was reviewed on 10/7/19 and required, " ...Autopsy photographs will be taken by the resident on service for every clinical autopsy ... Storing Autopsy Photographs: All photographs should be uploaded to the secure, departmental network drive "Pathology Surgical" as soon as possible following the completion of the autopsy but no later than sign-out of the PAD [preliminary autopsy diagnosis - due within 48 hours of completion of autopsy]... Photographs should not be stored on other drives, phones, desktops or on portable devices such as USB drives ...Photographs must be deleted from camera once it has been verified that they uploaded correctly to the network drive. It is the responsibility of the resident on service to ensure all photographs have been deleted from the camera as soon as possible following the completion of the autopsy but no later than sign-out of the PAD ..."

2. The "Autopsy Camera Theft - Summary", completed by the Integrity Officer (E #1), was reviewed on 10/7/19 and included:
- "Incident: On Monday, July 8, 2019 residents went to retrieve the camera used for autopsy photos, for an autopsy that was scheduled for that day. When they did not find the camera, a search was begun in the department of Histology, but the camera was not found. The camera had last been seen on July 1, 2019 at the completion of another autopsy...
- Investigation: The internal investigation focused on identifying what information may have been included on [the camera]; who may have had access to the device; and what was stored on the device at the time of the theft. Access to the device was complicated by the one week period between the last time when the camera was known to be there, and the time of discovery that it was not where it should have been. Review of the information stored on the camera is complicated by the fact that there is not an exact copy of the memory card ... on September 4 [2019], [resident] confirmed that they had deleted a lot of files from the camera. They explained that the memory card was nearly full when the new camera was purchased, and deleted nearly all of the files from prior to the end of the 2017 calendar year. With statements from 2 residents that they believed only a handful of cases on the camera were from 2017, we made the determination that our notifications would go back to October 2017."

3. On 10/8/19 at approximately 9:20 AM, an interview was conducted with the Integrity Officer (E #1). E #1 stated, "Most of the pictures [for the involved patients] got transferred, but for a few of the autopsies, the pictures were never uploaded. The pictures for the autopsies in May [2019] and June [2019] may not have been uploaded." E #1 stated that the camera was new as of April 2019. The camera did not come with a cable to upload the photographs, and the old cable did not work. E #1 stated that the photographs could not be uploaded due to this. E #1 stated, "I do not know if a new cable had been received by the time of the camera theft [identified on 7/8/19]."

4. On 10/8/19 at approximately 11:30 AM, E #1 presented a spreadsheet of the patients who had autopsies between April 1, 2019 (when new camera without upload cable was purchased) and July 1, 2019 (last autopsy performed before the camera was stolen). The spreadsheet indicated that the photographs for 9 (Pts #14 - #22) of the 18 patients who had autopsies were not uploaded into the patients' autopsy reports/medical records before the camera was stolen. Therefore, the autopsy reports/medical records were incomplete for these patients.

5. On 10/8/19 at approximately 9:30 AM, an interview was conducted with the Manager of Anatomic Pathology (E #3). E #3 stated that the photographs should have been uploaded into the autopsy report as part of the patients' medical record as soon as the autopsy was completed.