HospitalInspections.org

Based on policy review and staff interview, the facility failed to ensure employees were identified and trained as designated organ, tissue, and eye requestors. The findings were:

1. Review of the facility policy, "Organ and Tissue Donation Procedure'', no date, showed: "1. Potential Organ/Tissue Donors a) Any [facility] patient who is pronounced dead by the responsible provider will be considered a possible organ and/or tissue donor...To remain in compliance with CMS conditions of Participation, hospital staff shall not independently rule out any patients as potential donors. Donor Alliance, in consultation with appropriate medical criteria, shall determine medical suitability of each potential donor...3. Family Approach, b) A staff member who is a designated requestor is required to approach a family about donation when directed to do so by Donor Alliance. Designated requestors have received training through an organ procurement organization (OPO)...7. Education of Staff, a) An OPO-approved designated requestor training will be provided to [facility] staff annually..."

2. Interview with the patient care coordinator on 6/13/23 at 3:25 PM verified the facility had a "Notification of Death Checklist" with instructions to the clinical employees on what to do in the event of a death and the instructions included "notify the family", call the donor alliance within 1 hour of the death and complete the "deceased patient record" form and an "organ procurement contact" form. An additional interview with the patient care coordinator on 6/14/23 at 10:13 AM confirmed the facility collaborated with the Donor Alliance for organ, tissue and eye donation but the facility had not identified or trained designated requestors "for some time" and none of the current employees were up to date with either an initial or an annual training as required.