HospitalInspections.org

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure that the family's request for an autopsy was honored for one of one medical record reviewed (MR1)

Findings include:

A review of the facility policy "Autopsies and Coroner Cases...Definitions:...Inpatient Autopsy: An autopsy performed on a deceased inpatient which does not meet the criteria for notifying the coroner. Authorization for the autopsy by the patient's representative(s) must be obtained in accordance with this policy...II. Inpatient Autopsy:...B. The attending physician or designee will notify the family of the patient's death during which the physician will discuss, when appropriate, the option of an autopsy...1. In the event the family requests an autopsy independent of the physician, the attending physician will be contacted immediately to alert him/her of the family's request. 2. The physician is responsible for contacting the family and completing required signatures for authorization...C. An autopsy may be performed when written authorization (form 7181-179) has been obtained by the attending physician or designee..."

A review of MR1 revealed the following documentation: "10/8/2017 0130...Post Mortem Care:...All ADL's ( Airway, drains and lines) left in due to autopsy..."

"Discharge of the Deceased...Prior to release of body, ensure that RN Death Documentation is complete. Info from Post-Mortem Flowsheet Date of Death 10/7/2017 Autopsy Yes (per GOL(Gift of Life), family would like an autopsy. ICU resident aware) Time of Death 1432 Identified as a Coroner's Case No (per GOL representative ___(name redacted) already spoke to coroner and confirmed it was not a coroner's case)..."

An interview conducted on November 13, 2017, at 1:30 PM with EMP1 revealed an authorization for an autopsy was not completed by the physician for the family.