HospitalInspections.org

Based on record review and interview, the hospital failed to ensure patients were treated in a manner that maintained dignity. The deficient practice is evidenced by failing to remove indwelling tubes and lines postmortem in 1 (#1) of 3 (#1-#3) patients' medical records reviewed.

Findings:

Review of the hospital's policy titled, "Death of a Patient/Autopsy" revealed in part: POLICY: Deceased patients and their families are treated with respect, dignity, and compassion at all times. PROCEDURES: 4. Documentation: The nurse should complete an expiration note in the electronic medical record, indicating the date and time of death, the physician pronouncing the patient deceased, disposition of valuables, and post-death arrangements. Additional documentation will be necessary if the patient's death is deemed a coroner's case. 8. Preparation of the Body: a. After the family has left the hospital, the body is prepared and transported on the morgue cart to the morgue. The body is cleansed, all personal valuables are removed, insure that an ID bracelet is placed on the patient, and all indwelling tubes are removed. A paper isolation gown/hospital gown is placed on the body, then the body is placed in a plastic zippered body bag and tags to be placed on great toe, the zipper on the outside of the bag, and on any valuables.

Review of Patient #1's medical record revealed Patient was admitted to MICU on 06/19/2025 and expired on 06/20/2025 at 11:32 AM. Further review of Patient #1's expiration note revealed in part the following information:
Time of Death: On 06/20/2025 at 11:32 AM
Pronounced by S11MD
Notifications: Coroner; OPO; Funeral Home
Date/Time of Coroner Notification: 06/20/2025 at 12:58 PM
Not suitable for donation
Body released by Coroner: Yes
Lines, Drains, Airways: Yes
Body Cleaned? Yes
Body Preparation: placed in gown, body tagged, body bagged

Review of the Patient Care Service Record of Death for Patient #1 revealed The Coroner's office returned phone call regarding Patient #1's death at 4:05 PM on 06/20/2025 and released the body. Review of the morgue log Patient #1 was picked up from MICU on 06/20/2025 and transferred to the morgue at 6:00 PM. Further review of the morgue log revealed Patient #1 left the facility by the funeral home at 6:50 PM.

On 08/12/2025 at 1:20 AM S1VPPCS verified the above mentioned information, and Patient #1's indwelling tubes and lines were not removed per hospital policy.