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)
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..."