Mercy San Juan Medical Center has for years transported numerous deceased patients to an off-site morgue without notifying next-of-kin, leaving anguished families searching for loved ones who seemed to just disappear.
That's according to accusations in three California statements of deficiencies filed in the last 3 years. Investigators found the hospital failed to meet requirements for completing patients' death certificates within 15 hours, making sufficient attempts to notify family, and writing discharge summaries within 14 days.
The most recent violations at the 384-bed Dignity Health hospital in Sacramento were elevated to the federal level. State investigators acting on behalf of CMS discovered that as of Oct. 4, 2024, "the off-site morgue had 61 patient remains from the hospital, 11 patient remains from deaths in 2022, 15 patient remains from deaths in 2023, and 19 patient remains from deaths in the first half of 2024."
With a "known backlog of 61 patients stored in an off-site morgue," according to the deficiencies statement, "these failures resulted in a delay in completion of the death certificates, in notification to families of patient deaths, and in handling the patients' bodies after death ... [and] had the potential to prolong distress and grief for families."
The statement said investigators spoke with the hospital president -- identified on the hospital's website as Michael Korpiel -- who told them, "We assumed the remains being stored did not have families." He also said that the hospital's patient population "included high numbers of homeless persons."
The hospital's violations have prompted two lawsuits filed in Sacramento Superior Court on behalf of family members who were left frantically searching for their adult children -- in one case for a month, and in another, for just over a year.
"It Went Nowhere"
Mercy San Juan's supervisor of lab support services told investigators she knew the regional morgue office serving Sacramento hospitals "was failing to timely process patient remains and complete death certificate worksheets beginning in April 2023," the CMS violations notice said.
She tried to help reduce the backlog and reported it to the regional lab director and the hospital president but said "it went nowhere," adding that no log or documents were kept for the morgue until April 2024.
The hospital's regional morgue office was responsible for making three attempts to contact family once the patients' remains left the hospital, but "there was no expected time frame ... [and] until recently, there was no log to track the attempts," the CMS document stated. If the morgue couldn't find family, it was supposed to forward the case to the county public administrator who would make additional tries, and then contact the coroner to pick up the body. No documentation that had been done could be found.
Asked for a statement, Erica Pan, MD, director of the California Department of Public Health (CDPH) which conducted the investigations, told MedPage Today in an email: "The hospital failed to provide timely notification to families following the deaths of their loved ones, which is unacceptable."
"This caused unnecessary distress to families and prolonged their grief. We want families and all Californians to know we are working with the facility to ensure changes are made to prevent additional harm," she said.
Asked for a response to these accusations, a spokesperson for parent organization Dignity Health said in an email to MedPage Today: "Our goal is to provide the best care and support possible for patients and their families. Consistent with patient privacy laws and hospital policy, we respect our patients' privacy by not discussing the specifics of their care."
In a California statement of deficiencies dated April 2022, a hospital physician tried to notify two family members that the patient had died, but said the number for one family member was no longer in service and the other was invalid. However, a different phone number was listed as the patient's emergency contact.
"This failure resulted in Patient 1's family not being notified of Patient 1's death for 6 weeks," state investigators wrote.
Although the physician was supposed to complete a discharge summary within 14 days, the physician didn't get that done until 39 days later.
Mercy San Juan got in trouble again a year later, in May 2023, because of how it handled another deceased patient's body, which was sent to the hospital's morgue and picked up by an unknown entity. "Patient 1 expired and documentation of the location of the body was unknown," CDPH said in its deficiencies statement. "This failure resulted in Patient 1's son being unaware of his mother's body['s] whereabouts and caused family emotional distress."
"The morgue signature page did not have a signature or the location where Patient 1's body was taken, it was left blank, and the person picking up the body did not sign," the state document said.
"Left to Decompose"
Two lawsuits put names to two patients who died and who were transported to the off-site morgue without required notification.
In one lawsuit, the family of Jessie Marie Peterson alleges that they were told the 31-year-old who was admitted to Mercy San Juan for a diabetic episode on April 6, 2023 and died on April 8, "had been discharged against medical device."
Family members including her mother, Ginger Congi, tried to find her for a year. Finally, a sheriff's detective notified her that Jessie had died in the hospital. She called Mercy San Juan, but was told it didn't have her daughter. She was finally able to locate her daughter when she received a call later that day from a mortuary which informed Congi that Jessie was in one of Mercy San Juan's off-site storage facilities.
"Jessie was placed on Shelf Number Red 22 A and forgotten," the lawsuit stated. She "was left to decompose for nearly a year while her family relentlessly inquired about her whereabouts."
Jessie's death certificate, which was not completed until nearly a year later, said she died from cardiopulmonary arrest.
"Jessie's family was not notified of Jessie's passing, despite extensive previous contact between the hospital and Jessie's family," and though Congi was listed as the next-of-kin.
The lawsuit seeks $5 million in actual and statutory damages and $10 million in punitive damages for the hospital's "outrageous and inexcusable negligence and complete disregard for the dignity of Jessie and respect for the needs of Jessie's family," her attorney, Marc Greenberg, said in a press release last August.
An earlier lawsuit, filed in February 2022, recounts a similar issue regarding Michael Gray, who "died of an accidental overdose" while in that hospital. He had lived with his mother, Valerie Gray, who was never contacted about her son's death on July 10, 2021, "despite having his cell phone, wallet and identification with his current home address." Instead, the lawsuit says, the hospital treated him as "a John Doe."
Gray filed a missing person's report and tried to locate him, eventually enlisting the county sheriff, who found her son's body at an offsite storage facility "where it was neither autopsied or preserved."
His mother "was emotionally devastated and in shock upon Michael Gray's death and then the breakdown and mishandling of her son's body. She was not able to say her last goodbye to her son nor have a celebration of life with an open casket due to the state of the decedent's corpse."
The hospital claimed an unidentified chaplain had called his mother, but called the wrong number, and failed to leave a message or follow up, the lawsuit stated.
Gray's attorney, CT Turney-Lewis, told MedPage Today that Mercy San Juan settled the 3-year-long case in January for an undisclosed sum.
California licensing and certification officials can issue monetary fines to hospitals up to $125,000 in situations where the violation reaches a level called "immediate jeopardy" when the violation threatens imminent danger of death or serious bodily harm.
However, CDPH director Pan told MedPage Today that the violations "did not reach the level of immediate jeopardy, and the hospital was not fined. She said Mercy San Juan's plan of correction was accepted and corrections have been implemented."
Turney-Lewis said that even though Mercy San Juan's lapses did not cause physical harm, its practices certainly caused grief and anxiety, which do cause harm.
"Emotional impacts can certainly lead to physical issues with people that are suffering greatly," Turney-Lewis said, adding that although this off-site storage facility was refrigerated, it was not frozen, and does not halt all processes of decomposition.
"At least in the case of Ms. Grey's son, by the time they figured out what had happened to him ... some aspects of decomposition had already begun to take place. So harm is being caused to the families that have no knowledge of where their loved ones are."
Cheryl Clark has been a medical & science journalist for more than three decades.
https://www.medpagetoday.com/special-reports/features/114808
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