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.
|CHI ST LUKE'S PATIENTS MEDICAL CENTER||4600 EAST SAM HOUSTON PARKWAY SOUTH PASADENA, TX 77505||July 14, 2016|
|VIOLATION: AUTOPSIES||Tag No: A0364|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to report the death of Patient # 10 to the medical examiner per facility policy.
Review of complaint intake # TX 556 read : ..."I requested an autopsy, but was denied by the hospital unless I came up with at least $2,000.." Complainant stated the hospital should have done an autopsy because Patient # 10 died following recent procedures [Esophagogastroduodenoscopy and Percutaneous endoscopic gastrostomy (PEG) insertion tube.]
Record review on 07-13-16 of Patient # 10's clinical record revealed he was [AGE] year old male admitted to the facility on on [DATE] with chief complaint of fluid overload, congestive heart failure, missed dialysis and bilateral knee pain. Patient # 10 had a documented history of End Stage Renal Disease (ESRD) ; Diabetes Mellitus, and progressive weight loss/ failure to thrive.
Further review of Patient # 10's clinical record ( operative reports & nurses notes) revealed :
*04-02-15 [1:50 p.m. until 2:17 p.m.] : EGD and PEG tube insertion procedures were done.
*04-03-15 [11:38 a.m.]: family called for help, patient nonverbal and tongue protruding, rapid response team called...physician order written for ICU transfer.
*04-03-15 [1:15 p.m.] transferred to ICU .
* 04-03-15 [ 9:28 p.m.] rapid response called; medications administered; patient was intubated,cardiopulmonary resuscitation (CPR) and defibrillation was performed.
* 04-03-15 [ 10:10 p.m.] Patient # 10 was pronounced dead by the ER physician.
Record review of facility form for patient # 10 titled "Death Record", dated 04-04-15 ( 2250) read: "...5, Notification of Medical Examiner: Hospital deaths of the following types should be IMMEDIATELY reported to the Medical Examiner [facility capitalization & bolding] ...5. Deaths that occur during, following, or as a result of any diagnostic or therapeutic procedure in the hospital..."
Further review of this same form revealed it was completed by Registered Nurse (RN) #13 , who checked the box marked "NO" as an answer to the question:"Should this case be reported?"
Review of Nurses Notes, dated 04-04-15 ( 00:15) by RN # 13: "....Mrs. ( ) initially wanted an autopsy performed but stated she did not have the funds to pay for it..."
Interview on 07- at 10:30 a.m. with Vice President of Patient Services #1, she stated" I reviewed this case and our policy yesterday. The Medical Examiner should have at least been notified, especially since the wife requested an autopsy."
Review of facility policy titled: " Autopsy," dated October 2013, read: " Policy...A. Medical Staff members are required to report a death to the medical examiner when cause of death is questionable. A questionable death includes, but is not limited to,the following:...e.. Deaths that occur during, following, or as a result of any diagnostic or therapeutic procedure in the hospital..."