Lack of Postmortem Procedure Documentation
Summary
The facility failed to ensure that written postmortem procedures were available to all personnel, as evidenced by the lack of documentation in the clinical record of Resident CR81. The resident, who was admitted on 10/29/22, had diagnoses including metabolic encephalopathy, bacteremia, urinary tract infection, and severe protein-calorie malnutrition. On 11/15/24, progress notes indicated that Resident CR81 had ceased to breathe, yet the clinical record lacked documentation of the postmortem procedures. This deficiency was confirmed during an interview with the Regional Clinical Consultant on 1/31/25.
Plan Of Correction
Licensed staff will have access to the facility postmortem procedures that are located at the nurse's station and will be educated on postmortem care by the Director of Nursing/Designee. An audit will be conducted by the Director of Nursing/Designee weekly for 4 weeks of all deceased residents who cease to breathe each week to ensure residents receive postmortem care process and appropriate documentation and observations will occur using clinical documentation review and observation and interview of 3 staff members regarding the knowledge of the facility postmortem care policy and then monthly for 4 months. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Penalty
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