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Based on Organ Procurement Organization (OPO) contract review, OPO Tissue Donation Report review, in-service review, staff interview, and policy and procedure review, the facility failed to ensure the contracted OPO was notified of all patient deaths in a timely manner, within one (1) hour of a patient's death, for a combined total of 18 times from January 2016 to June 2017.

Findings Include:

Review of the facility's "2017 Donation Referral Compliance ..." revealed the following monthly data for untimely deaths called in to the OPO greater than one (1) hour after cardiac death: January/three (3), February/two (2), March/one (1) and May/two (2). The Summary/Analysis revealed: "January revealed " ...Three (3) deaths were referred more than one (1) hour after Cardiac Time of Death (CTOD) ...February ...Two (2) of the deaths were referred more than one (1) hour after CTOD ...March ...One (1) death was referred more than one (1) hour after CTOD ...May ...two (2) of the three (3) deaths were referred more than one (1) hour after CTOD ...".

Review of the facility's "2016 Donation Referral Compliance ..." revealed the following monthly data for untimely deaths called in to the OPO greater than one (1) hour after cardiac death: February/one (1), April/one (1), May/one (1), June/one (1), July/one (1), August/one (1), October/one (1) and November/three (3). The Summary/Analysis revealed: " ...February ...One (1) ER (Emergency Room) referral was called in more than one (1) hour after Cardiac Time of Death (CTOD) ...April ...One (1) of the deaths was referred more than one (1) hour after CTOD ...May ...One (1) of the deaths was referred more than one (1) hour after CTOD ...June ...One (1) of those deaths was referred more than one (1) hour after CTOD ...July ...One (1) of those deaths was referred more than one (1) hour after CTOD ...August ...One (1) of those deaths was referred more than one (1) hour ... after CTOD ...October ...One (1) death was referred more than one (1) hour after CTOD ...November ...Three (3) of the deaths were referred ...greater than one (1) hour after CTOD ...". The Referral Compliance Rate for September was 90%. The Summary Analysis revealed: " ...September ...There was one missed death referral ...".

Review of the facility in-services, dates 10/18/16 and 07/25/17, revealed the program was presented by the OPO representative and addressed notifying the OPO of all cardiac deaths within 60 minutes of cardiac time of death.

During an interview on 08/01/17 at 11:25 a.m., the Director of Quality Management confirmed a facility in-service was held on 07/25/17 for the Emergency Room, Intensive Care and Medical Surgical staff by the OPO representative and addressed the timely notification of the OPO within one (1) hour of a patient death.

During an interview on 08/01/17 at 12:40 p.m., the Director of Quality Management confirmed a staff in-service was held on 10/18/16 presented by the OPO representative and addressed the timely notification of the OPO within one (1) hour of a patient death.

During an interview on 08/01/17 at 3:00 p.m., the OPO findings were discussed with the Directory of Quality Management concerning the untimely reporting of deaths called into the OPO from January 2016 thru June 2017. She confirmed all the data findings and also confirmed that RNs (Registered Nurses) should call the OPO within one (1) hour of a patient's death.

During an interview on 08/02/17 at 9:35 a.m. RN#1 confirmed nurses were responsible for calling the OPO and should call within one (1 hour) of a patient death.

During an interview on 08/02/17 at 9:40 a.m. RN#2 confirmed that staff had been instructed to call the OPO within one (1) hour of a patient death.

During an interview on 08/02/17 at 9:43 a.m. RN#3 confirmed RNs call in their deaths within one (1) hour.

During an interview on 08/02/17 at 9:45 a.m. RN#4 confirmed RNs call in to the OPO within one (1) hour of death.

During an interview on 08/02/17 at 9:50 a.m. RN#5 and #6 both confirmed the nurses are responsible for calling the OPO and the timeframe was within one (1) hour or less of a patient death.

Review of the facility's "Organ/Tissue Donation" policy, revised November 2012, revealed: "Purpose: To define the process for organ and tissue donation ...Policy: ...B. All patients ...should be referred to the donor information line within one (1) hours of meeting said criteria as a organ referral ...C. All patients who cease cardiac and respiratory function should be referred to the donor information line as potential tissue donors ...Procedure: A. Potential Organ Donor Referral Procedure: 1. The Patient Care Coordinator (PCC)/Charge RN (Registered Nurse) or designee should contact the ...referral line ...to refer any potential donor ...B. Potential Tissue Donor Referral/Procedure: 1. Refer potential tissue donors as soon as possible after death has occurred ...".

Review of the facility's "Organ and Tissue Donation Cooperative Agreement entered into ...04/01/17" revealed: " ...Timely Notification for Organ Donation: A timely referral is one that is made as soon as possible (ideally within one (1) hour ...Timely Notification for Tissue Donation: For individuals who have died a cardiac death, notification is timely if the referral is made as soon as possible, ideally within one (1) hour of the cardiac death ...Section 1. Hospital Obligations ...1.2 Provide ...a Timely Notification for Tissue Donation or Timely Notification of Organ Donation ...".

These findings were discussed during the Exit Conference on 08/02/17 at 3:15 p.m. Nothing further was submitted for review.

Based on organ procurement organization (OPO) contract review, OPO Tissue Donation Report review, in-service review, staff interview and policy and procedure review, the facility failed to ensure the contracted OPO was notified of all patient deaths in a timely manner, within one (1) hour of a patient's death, in accordance with the facility OPO policy and procedure and OPO contract for a combined total of 18 times from January 2016 to June 2017.

Findings Include:

Cross Refer to A-0884 for the facility's failure to ensure the contracted OPO was notified of all patient deaths in a timely manner, within one (1) hour of a patient's death, in accordance with the facility OPO policy and procedure and OPO contract.