Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670031 (X3) Date Survey Completed 07/14/2016
Name of Provider or Supplier St Luke's Patients Medical Center Street Address, City, State 4600 East Sam Houston Parkway South, Pasadena, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0000 Note: The CMS-2567 is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. If information is inadvertently changed by the provider, you should notify the state Survey Agency. If the SA notices any discrepancy in the information related to scope and severity assigned or the deficiency citation (s), the SA will report this occurrence to the Dallas Regional Office. The Regional Office will make a referral of possible fraud to the Office of the Inspector General (OIG). Complaint # TX 00239556 was Unsubstantiated. An unannounced visit was made to conduct a complaint survey per Sections 5040, 5130 and 5210F of the State Operations Manual (SOM). Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals was utilized to determined hospital's compliance with 42 CFR 482 Conditions of Participation (CoP) for Hospitals regarding: Patient Rights,Medical Staff, Nursing Services, Food & Dietetic Services and Emergecny Services. An entrance conference was held on the morning of 07-13-16 with key administrative personnel. The purpose, scope and process of the complaint survey was explained and an opportunity for questions and discussion was provided. An exit conference was held on the afternoon of 07-14-16 with key administrative personnel. Findings of the investigation were discussed and again, an opportunity for questions and discussion was provided.
A0364 AUTOPSIES
CFR(s): 482.22(d)

The medical staff should attempt to secure autopsies in all cases of unusual deaths and of medical-legal and educational interest. The mechanism for documenting permission to perform an autopsy must be defined. There must be a system for notifying the medical staff, and specifically the attending practitioner, when an autopsy is being performed.


This STANDARD is not met as evidenced by:
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 00239556 Review of complaint intake # TX 00239556 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 53 year old male admitted to the facility on 03-24-15 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 07-14016 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..."