Delay in Death Certificate Signature Due to Communication Breakdown
Penalty
Summary
The facility failed to ensure that the Medical Director fulfilled their responsibility for timely implementation of resident care policies following the death of a resident. Specifically, after a resident with diagnoses including dementia, repeated falls, chronic kidney disease stage 3, and basal cell carcinoma died, the death certificate was not signed within the required 72-hour timeframe as mandated by State Public Health Law 4041. Documentation showed that the resident was found without respirations and an apical pulse, and post-mortem care was provided. The family and funeral home were notified, but the funeral home was unable to proceed with arrangements due to the unsigned death certificate, resulting in a delay of services. Interviews with the resident's representative and the funeral director confirmed that the delay in signing the death certificate caused additional stress and postponed the resident's services. The Medical Director stated that they were not informed in a timely manner to sign the certificate, as the nurse who documented the resident's expiration did not follow up with a phone call. The facility's investigation found no documentation that the Medical Director was contacted to sign the certificate, leading to the late signature. This breakdown in communication between nursing staff and the Medical Director resulted in the deficiency.