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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.

Findings include:

TX 556

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..."