The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MERCYHEALTH HOSPITAL ROCKTON AVENUE 2400 NORTH ROCKTON AVENUE ROCKFORD, IL 61103 Aug. 22, 2013
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, it was determined for 3 of 5 (Pt. #s 1, 6 and 8) clinical records reviewed, the hospital failed to ensure a physician pronounced the death of a patient.

Findings include:

1. Hospital policy titled, "Pronouncement of Death (reviewed 12/11)" stated in part, "It is the policy of Rockford Memorial Hospital that only a physician licensed in the State of Illinois who is a member of the Medical Staff of RMH will pronounce a patient dead."

2. The clinical record of Pt. #1 was reviewed on 8/19/13. Pt. #1 was an [AGE] year old female admitted on [DATE] with the diagnoses of respiratory distress, chronic obstructive pulmonary disease and dementia. A progress note written by a RN dated 10/22/12 at 9:00 AM included, " Pt. expired. No heart tones. No respirations. Dr. Brefeld notified. " The clinical record lacked documentation of a physician pronouncing death.

3. The clinical record of Pt. #6 was reviewed on 8/21/13. Pt. #6 was a [AGE] year old male admitted on [DATE] with the diagnosis of end stage renal disease. The Post Mortem flowsheet dated 6/16/13 included that Pt. #6 expired at 12:20 PM and was pronounced by a nurse with a second nurse witnessing the death. The clinical record lacked documentation of a physician pronouncing death.

4. The clinical record of Pt. #8 was reviewed on 8/21/13. Pt. #8 was a [AGE] year old female admitted on [DATE] with the diagnosis of cellulitis and gangrene of the right foot. The Post Mortem flowsheet dated 7/29/13 included that Pt. #8 expired at 10:40 PM and was pronounced by a nurse with a second nurse witnessing the death. The clinical record lacked documentation of a physician pronouncing death.

5. The Medical Director for the Hospitalists (E#8) was interviewed on 8/22/13 at 10:40 AM. When asked about the death pronouncing process in the hospital, E#8 stated, " it is hospital policy to have a physician pronounce the death of a patient. The physician should physically see the patient and pronounce the patient themselves. "