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ERLANGER MEDICAL CENTER 975 E 3RD ST CHATTANOOGA, TN 37403 Dec. 19, 2011
VIOLATION: QUALIFIED PERSONNEL Tag No: A0818
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, facility policy review and interview, the facility failed to ensure supervision for discharge planning per the facility policy for one (#5) of five medical record reviewed.

The findings included:

Patient #5, was born at the facility on November 13, 2011, at 12:15 a.m.

Medical record review revealed the infant was a NBVD (New Born Vaginal Delivery) of a VMI (Viable Male Infant) with an APGARs (scoring system used at five minute intervals to determine health status of newborns - with a total score 0 -10 and a score of 3 being critically low) score of 1/1/1, indicating the infant had blue extremities, heart rate less than 100 (160 normal), feeble cry, some flexion, and a weak grasp.

Medical record review revealed the infant was pronounced dead on November 13, 2011, at 12:55 a.m., 40 minutes after the birth of the infant.

Medical record review revealed the infant's mother was diagnoses as being in preterm labor at 19 weeks with Cervical Insufficiency and Advanced Cervical Dilatation upon arrival at the hospital on November 10, 2011, at 10:56 a.m. Continued review revealed the mother's physician admitted the mother in order to delay labor and place a stitch in the cervix. Continued review revealed on November 12, 2011, at 9:00 p.m., the mother was experiencing painful contractions every 5 -10 minutes and the amniotic sack had broken. Continued review revealed the mother's physician met with the mother to discuss options and the mother chose to proceed with the birth. Continued review revealed the mother gave birth to the pre-term, 250 gram (8.82 ounce), 18 week 6 day gestational aged infant, with the infant having positive cardiac activity on November 13, 2011, at 12:15 a.m.; and by 12:55 a.m., the infant was pronounced dead.

Medical record review of the nurses notation on the Bereavement Loss Check List located in the infant mother's medical record, dated November 13, 2011, at 8:40 a.m., revealed the disposition of infant body: Parent.

Medical record review of the infant mother's Detail Notes Log, dated November 13, 2011, revealed the following: "5:52 a.m. - alert and oriented times 3...ambulatory ...requesting pain medication...; 6:20 a.m. - Percocet 5 mg (milligrams) given...; 8:20 a.m. - awake, oriented ...; 8:40 a.m. - patient in shower ...; 9:36 a.m. - discharge home ...discharge information given ...verbalizes understanding; 9:50 a.m. - Infant wrapped in blankets and placed in Styrofoam box. Infant given to patient along with correct paperwork; 10:00 a.m. - Patient off floor via wheelchair in stable condition. Accompanied by FOB (father of baby) and patient's mother ..."

Medical record review of the form Notification of Disposal of Fetal Remains, dated November 13, 2011, no time noted, revealed the initials of the infant's mother in the area indicating " ...I wish for the remains to be released to someone other than a licensed funeral director. That person may be ...the mother of legal father as defined in the Birth Clerk Instructions Manual ...This method of disposal may incur burial permit charges or State or local charges, and I understand that I am responsible for payment of these charges ...I acknowledge the Erlanger has: Advised me of any known local ordinances pertaining to where burial may occur, and that it is my responsibility to find out what the local ordinances are regarding burial. Advised me that the body must be disposed of within forty-eight (48) hours. The body is intended to be disposed of by ('Burial' written in space) at ('to be buried at infant's primary residence' written in space) ...Advised me that I must obtain a Burial Transit Permit from the Chattanooga-Hamilton County Health Department, or if after hours, from Erlanger's Registrar for Burial Transit Permit at the facility (House Supervisors) ...(signatures of mother of the infant and Labor and Delivery staff nurse discharging the mother of the infant) dated November 13, 2011.

Medical record review of the form Record of Death, dated November 13, 2011, no time noted when signed by mother, revealed the named infant's mother signed the approval to " ...release the remains of (named infant) to the (mother's name written out and 'self' identified as relationship to patient) ..."

Medical record review of the form Permit for Final Disposition of Human Remains, dated November 13, 2011, no time noted, revealed " ...(named infant) ...date of death [DATE] ...TRANSIT From: Erlanger To: Home ...PERMIT OF LOCAL OR DEPUTY REGISTRAR...for the final disposition of the remains ...(signature of House Supervisor) November 13, 2011 ..."

Interview, in the morgue on November 22, 2011, at 3:50 p.m., with the House Supervisor revealed " ...the House Supervisor on duty (at the time of the discharge of named infant) would have taken the morgue log to the floor for the mother to sign and get the TRANSIT form signed by the responsible person when this occurred after hours or on weekends. The county Health Department would generally handle things otherwise ..."

Interview, in the office of the Chief Executive Officer, on November 22, 2011, at 4:05 p.m., with the Manager of Risk Management, an attorney, reported the the facility policies related to the identification, handling, and disposition at discharge of live birth versus stillbirth infant remains to a parent were conflicting.

Interview, by phone on November 23, 2011, at 1:15 p.m., with the Labor and Delivery (L&D) staff nurse discharging the mother of the infant revealed the infant died not long after mid-night ...the mother was brought to L&D and slept ...night shift reported everything was done except the mother selecting a funeral home and the paperwork associated with that ....the mother told (staff nurse) she wanted the baby home with her ...explained to mother that could be done and it would be up to mother to gather the information about burying the baby on her property ...told mother she would need to call the county office or could look it up on line to get the information ...the (deceased infant's maternal grand-mother) wanted some testing done and was informed that could be done if the infant's mother wanted it ...the mother said 'no, I want to take the baby home' ...during the process the Charge Nurse gave clarification and directives throughout ..."

Interview, by phone, on November 28, 2011, at 2:30 p.m., with the L&D Charge Nurse on duty at the time of the deceased infant's mother, revealed " ...involved in ensuring all discharge paperwork was completed correctly ...checked the discharging nurse's paperwork and did clarification to ensure the discharging nurse went over the forms, gave the patient time to ask questions, and was clear with the discharging nurse that the patient must own the property. The discharging nurse said the patient reported the property belonged to her ...I have done this (discharge of infant remains to home with the parent) before ...I took care of this patient the day before ...at discharge the patient, the patient's mother, or the deceased infant's father never said anything (related to not having money to bury the baby) and hugged the staff and thanked us for the good care ...the patient signed the forms in the morgue log then took a shower ...the deceased infant was stored in a specimen refrigerator until the time of discharge and was placed in a Styrofoam container (for transport) ...We offered the Medical Examiners Frequently Asked Questions but the patient declined ...We explained to her it was her responsibility to find out if any fees would be involved ...Did not offer to keep the remains until all arrangements were made as the patient was insistent and clear she was taking the infant home ...had not given any indication of wanting a funeral but to the contrary wanted to bury the infant at home ...The patient has to state out loud who is taking the baby and what they intend to do with the remains ..."

Interview, by phone, on December 2, 2011, at 6:40 p.m., with the House Supervisor on duty at the time of the discharge of the deceased infant's mother, revealed the house supervisor is over a body being signed out. Continued interview revealed the transfer sheet is signed by the house supervisor and the paperwork given to the transporter of the body. Continued interview revealed the house supervisor asked the L&D charge nurse if the deceased infant's mother was competent and was informed the mother was competent. The question was asked as it was rare to have an infant's remains released to the family to go home. In the past the house supervisor reported only releasing 2 infant bodies and 1 adult body to the family in the past five years. Continued interview revealed the house supervisor had no concerns as the cooler was closed, the sticker identification was on the blanket, and the supervisor checked the identification band present on the infant to ensure the correct identifying information was present. Continued interview revealed the facility policy for releasing remains to a family member were followed. Continued interview revealed the Huose Supervisor felt the facility policies were conflicting related to identification and handling of infant remains compared to stillbirths. Continued interview revealed the House Supervisor would suggest the facility make clarification related to the various definitions and procedures within the policy.

Review of the facility policy Care of Fetal Death, #8308.058, dated revised September 2010, revealed "...to ensure accurate and through care to the stillborn and family members...any infant born (regardless of gestational age or weight) that shows any signs of life (heart beat or breath), even though it may be momentarily, is considered a live birth...must be admitted ...a birth certificate filed as well as a death certificate...Procedure: Equipment:...Record of Death..."

Review of the facility policy Deaths (Labor and Delivery), #8028.P0202, dated February 2009, revealed "...If L&D has a...fetal demise...the baby's body must be released to a funeral home...If the parents want to take the baby's body with them and not use a funeral home, the father needs to go the health department...after the health department obtains all the necessary information for the death certificate, the baby's body will be placed in a Styrofoam container and given to the parents..."

Interview by phone with the Director of Nursing Quality, on December 19, 2011, at 10:50 a.m., confirmed the facility failed to follow the policy on the discharge process for infant remains of ensuring the death certificate was obtained prior to the release of the infant remains to the family.

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