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Based on review of credential files and personnel records, the facility failed to ensure that licensure information was up to date for 8 (Z, AA, AB, AC, AD, AE, AF and AG) of 13 physicians and 1 (T) of 2 CNA records. Findings include:

1. During review of physician credential files on 8/17/10 at 3:15 p.m., the 8 physicians (Z, AA, AB, AC, AD, AE, AF and AG), that were under contract for radiology services, did not have current licensure information in the credential files. Three of the physicians' licenses had expired on 3/31/09; 5 licenses had expired on 3/31/10. The radiologists were still working even though their licenses had expired.

2. During review of employee files on 8/18/10 at 1:00 p.m., CNA T did not have a current certification in the record.

Based on observation and staff interview, the facility failed to ensure that outdated supplies were not available for patient use in the ED, the nursing station, the supply cart, the laboratory, the CT room, and the supply room. Findings include:

1. During the tour of the facility on 8/17/10 beginning at 8:30 a.m., the following outdated supplies were noted:
In the ED:
- 2 red top 3.5 mL Vacuette blood tubes, with the manufacturer's expiration date of 6/10;
- 1 tube of Surgical lubricant, with the manufacturer's expiration date of 5/08; and
- 1 full package of resting EKG electrodes, with the manufacturer's expiration date of 02/10.
At the nursing station:
- 3 red top 5 mL Vacuette blood tubes, with the manufacturer's expiration date of 4/10; and
In the supply cart:
- 1 female catheterization kit, with the manufacturer's expiration date of 3/09; and
- 1 disposable urethral catheterization tray, with the manufacturer's expiration date of 5/10.
In the supply room:
- 4 bottles of roll-on deodorant, with the manufacturer's expiration date of 5/09.

2. On 8/16/10 at 8:45 a.m., the DON stated the facility nurses check weekly for expired supplies in the emergency room. The DON stated she checks monthly for expired in the emergency room.

3. On 8/18/10 at 11:10 a.m., the DON stated her nursing staff check for expired supplies twice a week in the emergency room and medical floor. She checked once a month for expired supplies.


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4. During the tour of the CT scan room on 8/17/10 at 8:20 a.m., the following expired supplies were noted:
- 5 packages of 18 gauge BD Insyte Autoguard intravenous catheters, with the manufacturer's expiration date of 4/09;
- 1 full package of Medi Trace ECG electrodes, with the manufacturer's expiration date of 12/07;
- 2 packages of 22 gauge BD Insyte Autoguard intravenous catheters, with the manufacturer's expiration date of 5/09;
- 1 package of 22 gauge BD Insyte Autoguard intravenous catheters, with the manufacturer's expiration date of 5/09; and
- 1 60 mL syringe, with the manufacturer's expiration date of 5/10.

At 8:20 a.m., the head of the imaging department N, stated an imaging employee S, reordered when supplies were running low.

Based on observation and staff interview, the facility failed to ensure that multi-dose vials of medications were dated when opened, and disposed of as per facility policy. Findings include:

1. During the tour of the ED on 8/17/10 at 8:30 a.m., the following was noted:
- 1 vial of Lidocaine 2% and Epinephrine 1:100,000 Injectable was opened and a date was not recorded;
- 1 vial of Marcaine 0.5% with the open date of 6/30;
- 1 vial of Marcaine 0.5% with no open date; and
- 1 vial of Xylocaine 1% with no open date.

2. During the tour on 8/17/10 at 8:30 a.m., the accompanied the surveyors. The DON was asked about the facility policy on opened multidose vials. The DON replied the facility policy was to dispose of opened multidose vials 30 days after opening. The DON was given the opened multi-dose vials to dispose of them.

Based on record review and staff interview, the facility failed to ensure that patient records were complete to include signatures, and dates and/or times of document entries by health care disciplines and by physicians and mid-level practitioners; and failed to ensure transfer documents were included in patient records. Findings inlcude:

1. The patient records for 13 (#s 4, 5, 6, 7, 12, 14, 15, 16, 21, 23, 29, 30, and 31) were not completed by nursing staff, speech therapy staff, physical therapy staff, and activities staff with respect to signatures, timing, and dating. (See C302.)

3. The Request for Transfer, Consent to Transfer, and Certification for Transfer forms were not signed, dated, and timed for patient #s 18 and 24. (See C304.)

4.. The Request for Transfer, Consent to Transfer, and Certification for Transfer forms were not completed at all for patient #s 8, 23, and 26. (See C304 and C306.)

5.. All entries in patient records by physicians and mid-level practitioners were not completed with respect to signatures, time of day, and date for 28 (#s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 29, 30, and 31) records. (See C307.)




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Based on record review and staff interview, the facility failed to ensure medical records were complete relative to nursing, speech therapy, physical therapy, and activity staff documentation for 13 (#s 4, 5, 6, 7, 12, 14, 15, 16, 21, 23, 29, 30, and 31) of 31 patient records sampled. Finding include:

1. Patient #23 was brought to the ED on 8/9/10 at 7:30 a.m., with complaints of chest pain. The Chest Pain or Suspected AMI Protocols were not signed by the nurse.

2. Patient #5 was seen in the ED on 6/24/10. The Nursing Record was not signed by the nurse.

Patient #5 was admitted to swing bed status on 7/9/10. ST notes dated 7/11 and 8/6/10 were not timed when written. PT notes dated 7/10, 7/12, 7/13, 7/15, 7/16, 7/17, 7/19, 7/20, 7/21,7/22, 7/23, 7/26, 7/27, 7/28, 7/29, 7/30, 7/31, 8/2, 8/3, 8/4, 8/5, and 8/6/10 were not timed when written.

3. Patient #12 was admitted on 9/28/09 and died on 10/10/09. PT notes, dated 9/30, 10/1, 10/2, 10/5, 10/6, 10/7, 10/8, 10/9, and 10/10/09, were not timed when written.

4. Patient #14 was seen in the ED on 9/10/09 and admitted to swing bed status. There were three notes written by the nurse, with the times of 2020 (10:20 p.m.), 2300 (11:00 p.m.), and 0630 (6:30 a.m.). Each note was without a date.

5. Patient #16 was admitted on 5/18/10 and died on 5/23/10. A PT note dated 5/19/10 was not timed when written.

6. Patient #29 was admitted to swing bed status on 6/11/10 and discharged on 7/2/10. PT notes dated 6/12, 6/13, 6/15, 6/16, 6/17, 6/18, 6/21, 6/22, 6/23, 6/24, 6/25, 6/28, 6/29, 6/30, and 7/1/10, were not timed when written. Activities Progress Notes dated 6/12, 6/14, 6/18, and 6/22/10 were not timed when written.

7. Patient #30 was admitted to swing bed status on 12/30/09 and discharged on 1/27/10. Activity progress notes dated 12/30/09, 1/6, 1/13, and 1/26/10 were not timed when written.

8. Patient #31 was admitted to swing bed status on 7/19/10 and discharged on 8/13/10. PT notes dated 7/19, 7/20, 7/21, 7/22, 7/23, 7/26, 7/27, 7/28, 7/29, 7/30, 7/31, 8/2, 8/3, 8/4, 8/5, 8/6, 8/9, 8/10, 8/11, 8/12, 8/13/10 were not timed when written. Activity progress notes dated 7/20 and 7/23/10 were not timed when written.

9. Patient #4 was admitted to the ED on 6/4/10. The Nursing Record contained four notes written by the nurse, with the times of 2:48 a.m., 2:50 a.m., 2:54 a.m., 3:00 a.m., and 3:07 a.m. These notes were not dated when written. One note on the same page had no date or time when it was written.

10. Patient #6 was admitted to the ED on 6/27/10. The Nursing Record contained four notes written by the nurse, with the times of 6:29 p.m., 7:31 p.m., 7:38 p.m., and 10:15 p.m., without any dates. One note on the same page was not dated or timed.

11. Patient #7 was admitted to the hospital on 8/13/10. The PT Progress Note dated 8/16/10 was not timed when written.

12. Patient #15 was seen in the ED and admitted to the hospital on 9/3/09. The Emergency Nursing Record General Medicine Complaints form was not dated by the nurse.

13. Patient #21 was admitted to the ED on 8/12/10. The Emergency Department Record Physician Order Sheet and the Emergency Nursing Record Extremity Trauma form written on 8/12/10 were not timed.

Based on record review and staff interview, the facility failed to ensure that properly executed Request For Transfer/Consent to Transfer/Certification For Transfer forms were obtained for 5 (#s 8, 18, 23, 24, and 26) of 10 transfer records reviewed. Findings include:

1. Patient #18 was brought to the ED on 6/24/10 at 7:19 p.m., complaining of middle chest to left side pain. Patient #18 was admitted to the facility at 8:40 p.m.

The facility's midlevel practitioner wrote an order on 6/27/10 at 11:40 a.m., "Emergency Transfer by ambulance to [Transferring Facility Name] ED."

The facility's midlevel filled out the Request For Transfer/Consent to Transfer/Certification For Transfer form. The form lacked the patient's consent or the consent of family representative, the date, time, and signature of the witness.

2. Patient #23 was brought to the ED on 8/9/10 at 7:30 a.m., with complaints of chest pain. On 8/9/10 at 1:00 p.m., the physician wrote in the Progress Note, "...Repeat troponin 0.78 [to] 2.00...P. Have discussed case [with] [Physician name] in [Town name], will transfer by ambulance for cath." Review of the medical record showed there was no Request For Transfer/Consent to Transfer/Certification For Transfer form.

3. Patient #24 was brought to the ED on 7/26/10 at 1:01 p.m., following a fall from an 8 foot roof. The physician noted the patient had a comminuted fracture of the right proximal tibial/fibula with fractured joint. The physician noted the patient needed to be transferred to a higher level of care. The Request For Transfer/Consent to Transfer/Certification For Transfer form was lacking the risk versus benefits for transfer, the patient's consent or the consent of family representative, the date, and time.

4. Patient #26 was brought to the ED on 7/17/10 at 9:15 p.m., following a motorcycle accident. The trauma team was activated. The patient was transferred to a higher level of care hospital via Life Flight. Review of the medical record showed there was no Request For Transfer/Consent to Transfer/Certification For Transfer form.

On 8/18/10 at 10:05 a.m., the DON stated the facility could not find the Request For Transfer, Consent to Transfer, and Certification For Transfer form for patient #26. The DON stated the doctor who cared for patient #26 usually filled out Request For Transfer/Consent To Transfer/Certification For Transfer form.


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5. Patient #8 was brought to the ED on 8/2/10 following a motor vehicle accident. The trauma team was activated. The patient was transferred to a higher level of care hospital via Life Flight. Review of the medical record showed there was no Request For Transfer/Consent To Transfer/Certification For Transfer form present. In the Plan of Care section, the physician documented, "Due to risk of pulmonary compromise, will arrange life flight transport to [hospital name]."

6. During an interview on 8/18/10 at 10:05 a.m., the DON stated one of the facility's physician did not fill out a transfer form if the transfer was non-emergent. The physician did not complete a transfer form for patient #s 8 and 24.

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Based on record review and staff interview, the facility failed to maintain complete medical records regarding transfer forms for 4 (#s 8, 18, 23, 24, and 26) of 4 transfer patients sampled. Findings include:

1. Patient #18 was brought to the ED on 6/24/10 at 7:19 p.m., complaining of middle chest to left side pain. The Emergency Physician Record Chest Pain and the Emergency Physician Record Cardiopulmonary Resuscitation form was not dated or timed when signed by the physician. Patient #18 was admitted to the facility at 8:40 p.m.

The facility's midlevel practitioner wrote an order on 6/27/10 at 11:40 a.m., "Emergency Transfer by ambulance to [Transferring Facility Name] ED."
The facility's midlevel filled out the Request For Transfer/Consent to Transfer/Certification For Transfer form. The form lacked the patient's consent or the consent of family representative, the date, time, and signature of the witness.

2. Patient #23 was brought to the ED on 8/9/10 at 7:30 a.m., with complaints of chest pain. The Emergency Department Record Physician Order Sheet was not dated, timed, or signed by the physician. The Chest Pain or Suspected AMI Protocols were not signed by the physician or the nurse. On 8/9/10 at 1:00 p.m., the physician wrote in the Progress Note, "...Repeat troponin 0.78 [to] 2.00...P. Have discussed case [with] [Physician name] in [Town name], will transfer by ambulance for cath." Review of the medical record showed there was no Request For Transfer/Consent to Transfer/Certification For Transfer form.

3. Patient #24 was brought to the ED on 7/26/10 at 1:01 p.m., following a fall from an 8 foot roof. The Emergency Department Record Physician Order Sheet was not timed, dated, or signed. The Emergency Physician Record Lower Extremity Injury form was not dated or timed by the physician. The physician noted the patient had a comminuted fracture of the right proximal tibial/fibula with fractured joint. The physician noted the patient needed to be transferred to a higher level of care. The Request For Transfer/Consent to Transfer/Certification For Transfer form was lacking the risk versus benefits for transfer, the patient's consent or the consent of family representative, the date, and time.

4. Patient #26 was brought to the ED on 7/17/10 at 9:15 p.m., following a motorcycle accident. The trauma team was activated. The patient was transferred to a higher level of care hospital via Life Flight. Review of the medical record showed there was no Request For Transfer/Consent to Transfer/Certification For Transfer form.

On 8/18/10 at 10:05 a.m., the DON stated the facility could not find the Request For Transfer/Consent to Transfer/Certification For Transfer form for patient #26. The DON stated the doctor who cared for patient #26 usually filled out the Request For Transfer/Consent To Transfer/Certification For Transfer form.

5. During an interview with the DON on 8/18/10 at 10:05 a.m., DON stated one of the facility's physician did not fill out a transfer form if the transfer was non-emergent. The physician did not complete a transfer form for patient #s 8 and 24.

Based on record review, the facility failed to ensure that all entries in the medical record were authenticated by the physician and/or mid-level practitioners, which included signature, date and time of the entry for 28 (#s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 29, 30, and 31) of 31 sampled patient records. Findings include:

1. Patient #1 was seen in the ED on 5/21/10. The Emergency Department Record Physician Order Sheet was not signed by the physician.

2. Patient #3 was seen in the ED on 6/6/10. The Emergency Department Record Physician Order Sheet was not signed by the physician. The handwritten transfer note written by the physician did not have a time when the note was written.

3. Patient #5 was seen in the ED on 6/24/10. The Emergency Department Record Physician Order Sheet was not signed by the physician.

Patient #5 was admitted to swing bed status on 7/9/10. Physician orders dated 7/9, 7/10 (3 orders), 7/14 (3 orders), 7/19, and 7/29/10 were not timed when written. Physician progress notes dated 7/13 and 7/28/10 were not timed when written.

4. Patient #8 was seen in the ED on 8/2/10. The Emergency Department Record Physician Order Sheet was not signed by the physician. The History and Physical form was signed by the physician, but was not dated or timed.

5. Patient #10 was admitted on 1/6/10 and died on 1/16/10. Physician's orders, dated 1/9 and 1/14/10 did not have a time when written by the physician. Physician's progress notes dated 1/8, 1/10, 1/11, 1/12, and 1/14/10 were not timed when written.

6. Patient #12 was admitted on 9/28/09 and died on 10/10/09. The Discharge Summary was not signed or dated by the physician. A verbal order to discontinue colace, Senakot and metoprolol was noted, but there was no date or time noted for the order. Physician orders, dated 9/28, 9/29, 10/5, and 10/6, were not timed when written. PT notes, dated 9/30, 10/1, 10/2, 10/5, 10/6, 10/7, 10/8, 10/9, and 10/10/09, were not timed when written.

7. Patient #16 was admitted on 5/18/10 and died on 5/23/10. The History and Physical was not dated or timed when signed by the physician. Progress Notes written by the physician on 5/17 and 5/18/10 were not timed when written. The Physician Orders form was not timed when written by the physician.

8. Patient #29 was admitted to swing bed status on 6/11/10 and discharged on 7/2/10. Physician orders dated 6/11, 6/14 and 7/2/10 were not timed when written.

9. Patient #30 was admitted to swing bed status on 12/30/09 and discharged on 1/27/10. Physician orders dated 12/30/09, 1/5, 1/6, and 1/19/10 were not timed when written. A physician's admit note was not timed when written on 12/30/09. The Discharge Orders and Instructions form was signed and dated by the provider, but no time was noted.

10. Patient #31 was admitted to swing bed status on 7/19/10 and discharged on 8/13/10. Physician orders dated 7/19, 8/10, and 8/13/10 were not timed when written. Physician progress notes dated 7/20 and 8/4/10 were not timed when written.


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11. Patient #4 was admitted to the ED on 6/4/10. The Emergency Department Record Physician Order Sheet was not dated, timed, or signed by the physician. The Emergency Physician Record Cardiopulmonary Resuscitation form was not dated or timed when signed by the physician.

12. Patient #6 was admitted to the ED on 6/27/10. The Emergency Department Record Physician Order Sheet was not dated or timed when signed by the midlevel practitioner.

13. Patient #7 was admitted to the hospital on 8/13/10. The Progress Notes dated 8/13 (2 notes), 8/16, and 8/17/10 were not timed when written. The Physician Order written on 8/18/10 was not timed when written.

14. Patient #9 was admitted to the hospital on 7/19/10. The Doctor's Order Sheet dated 7/19/10 (2 orders) and 7/20/10 (2 orders) were not timed when written. One physician order for the UA-reflex to culture was not timed or dated when written.

15. Patient #11 was seen in the ED and admitted to the hospital on 7/6/10. The Emergency Department Record Physician Order Sheet was not dated or timed when signed by the physician. The Emergency Physician Record Altered Mental Status was not timed, dated, or signed by the physician. The Physician Orders dated 7/6, 7/8, 7/9, and 7/10/10 were not timed when written. The Progress Notes written on 7/8 and 7/9/10 were not timed.

16. Patient #13 was admitted to the hospital on 2/1/10. The Physician Order dated 2/2/10 was not timed when written. The History and Physical written 2/2/10 was not timed when written. The Progress Note written on 2/4/10 was not timed.

17. Patient #15 was seen in the ED and admitted to the hospital on 9/3/09. The Emergency Department Record Physician Order Sheet was not dated or timed when signed by the physician. The Emergency Physician Record Dyspnea form was not dated or timed when signed by the physician. The History and Physical written on 9/3/09 was not timed. The Discharge Summary written on 9/7/09 was not timed. The Physician Orders dated 9/3 (5 orders) and 9/4/09 (2 orders) were not timed when written. The Progress Notes written on 9/4, 9/5, 9/6, and 9/7/10 were not timed.

18. Patient #17 was admitted to the hospital on 8/15/10. The History and Physical written on 8/15/10 was not timed. The Progress Notes dated 8/14, 8/16, and 8/17/10 were not timed when written. The Physician Orders dated 8/16 (2 orders) and 8/17/10 were not timed when written.

19. Patient #18 was admitted to the hospital on 6/24/10. The Emergency Physician Record Chest Pain and the Emergency Physician Record Cardiopulmonary Resuscitation was not dated or timed when signed by the physician.

20. Patient #19 was admitted to the hospital on 7/24/10. The Physician Orders dated 7/24/10 were not dated when signed by the physician. The Emergency Department Record Physician Order Sheet and Emergency Physician Record Abdominal Pain/Flank Pain were not dated or timed when signed by the physician.

21. Patient #20 was admitted to the hospital on 8/10/10. The History and Physical written on 8/10/10 was not timed. The Discharge Summary written on 8/11/10 was not timed. The Physician Orders dated 8/10/10 (2 orders) were not timed when written.

22. Patient #21 was admitted to the ED on 7/27/10. The Emergency Department Record Physician Order Sheet and the Emergency Physician Record Chest Pain written on 7/27/10 were not timed.

Department Record Physician Order Sheet and the Emergency Nursing Record Extremity 25. Patient #21 was admitted to the ED on 8/12/10. The Emergency Trauma written on 8/12/10 were not timed.

23. Patient #22 was admitted to the ED on 8/14/10. The Emergency Department Record Physician Order Sheet was not dated or timed by the midlevel practitioner.

24. Patient #23 was admitted to the ED on 8/9/10. The Emergency Department Record Physician Order Sheet was not dated, timed, or signed by the physician. The Chest Pain or Suspected AMI Protocols were not signed by the physician.

25. Patient #24 was admitted to the ED on 7/26/10. The Emergency Department Record Physician Order Sheet was not timed, dated, or signed. The Emergency Physician Record Lower Extremity Injury was not dated or timed by the physician.

26. Patient #25 was admitted to the ED on 7/18/10. The Emergency Department Record Physician Order Sheet was not timed, dated, or signed. The Emergency Physician Record Hip Injury/Pain was not dated or timed by the physician. The Progress Noted written on 7/8/10 was not timed.

27. Patient #27 was admitted to the hospital on 7/19/10. The Physician Orders dated 7/19 (2 orders) and 7/20/10 were not timed when written.

Based on staff interview and review of the annual program review, the facility failed to ensure the facility's total program was reviewed at least annually. Findings include:

On 8/18/10 at 3:05 p.m., during the Quality Assurance review with the Human Resources person, C, the annual plan for 2009 was discussed. Staff C stated the review for 2009 was the first year they had an annual review. Staff C provided a copy of the dashboard report and the 2009 Program Review. Staff C was unable to produce annual reports for any year other than 2009.

Based on staff interview and review of the annual program review for 2009, the facility failed to ensure a representative sample of both active and closed clinical records was reviewed during the annual program review. Findings include:

During the Quality Assurance Review with the Human Resources person, Staff C, the staff member stated they did not review a sample of active and closed records during the annual program review.

Review of the program review for 2009, provided by Staff C, failed to show the records were reviewed. Only the number of emergency room visits was addressed. Nothing about record review of any records was noted in the information.

Based on record review, facility policy review, and staff interview, the facility failed to implement written protocols for organ donation for 5 (#s 9, 10, 13, 15, and 16) of 10 sampled patients. Findings include:

1. In the facility's policy Organ Procurement under the section labeled Procedure, the policy reads: "The Donor Inquiry/Funeral Home Form will then be completed by the nursing staff. A reference number will be given to the [Facility Name] nursing staff by the Donor Information staff (Procurement Coordinator) for either a donor refusal of [sic] for a positive donor. The name of the Procurement coordinator must also appear on the form with the reference number."

Record review revealed the OPO was notified of the death of three patients (#s 9, 13, and 15). The Death Notification form in each patient's record lacked documentation of the Procurement Coordinator's name and the reference number for each identified patient. (See C345.)

2. Record reviewed revealed the OPO was not notified of the death of two patients (#s 10 and 16). The computer generated Death Notification form found in both records did not indicate the OPO was notified. In patient #10's record, recorded on the Death Notification form was "coordinator not called for family reasons." In patient #16's record, recorded on the Death Notification form was "Family declined." (See C345.)

3. An interview with the DON revealed that the OPO was not called when the patient had an Advance Directive indicating the patient did not want to donate organs or the patient's family refused to donate the organs on the patient's behalf. (See C345.)

4. The facility failed to collaborate with the OPO to involve family in the decision of organ donation for two (#s 10 and 16) of 10 patients reviewed. (See C347.)

5. The facility failed to create and implement protocols addressing the education of staff about the donation process. (See C349.)

Based on record review, facility policy review, and staff interview, the facility failed to implement the written protocols and notify the OPO of the deaths of 5 (#s 9, 10, 13, 15, and 16) of 10 sampled patients . Findings include:

1. In the facility's policy Organ Procurement under the section labeled Procedure, the policy reads: "It is, however the policy of [Facility's name] to place a telephone call to the donor information number at [phone number] as soon as possible following ALL deaths in the hospital."

2. Patient #9 was an 85 year-old female patient who passed away on 7/10/10 at 2:35 a.m. While the OPO was notified of the patient's death, the Death Notification Form lacked documentation of the Procurement Coordinator's name and the reference number.

3. Patient #13 was an 87 year-old female patient who passed away on 2/8/10 at 2:55 a.m. While the OPO was notified of the patient's death, the Death Notification Form lacked documentation of the reference number.

4. Patient #15 was a 72 year-old female patient who passed away on 9/7/09 at 6:20 p.m. While the OPO was notified of the patient's death, the Death Notification Form lacked documentation of Procurement Coordinator's name.

5. On 8/17/10 at 4:10 p.m., day shift nurse M, was interviewed about the facility's policy on organ procurement. Nurse M stated she had not worked at the facility long and had not had a death since coming to the facility. Nurse M stated she would look at the facility's policy on patient death. The DON told nurse M that she (DON) would call the OPO. Nurse M stated she would still look at the facility's policy.

6. On 8/18/10 at 6:56 a.m., night shift nurse J, was interviewed about the facility's policy on Organ Procurement. Nurse J stated she would call the OPO on every death, unless the patient designated on the advance directive of not being an organ donor. Nurse J stated she would have called Lion's eye bank about the patient's eyes. The facility does not have an agreement with Lion's eye bank.

7. On 8/18/10 at 9:55 a.m., the DON stated if the patient had an advance directive indicating not to donate organs or the patient's family refused to donate the organs on the patient's behalf, the OPO did not need to be called.

8. On 8/18/10 at 11:00 a.m., the DON stated the facility did not call the OPO due to the family not wanting them to be called.


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9. Patient #10 was a 59 year-old female admitted to swing bed status on 1/6/10 and died on 1/16/10. On the facility's computer generated Death Notification Form, the nurse noted the OPO "coordinator not called for family reasons." There was no evidence in the medical record that the OPO had been contacted.

10. Patient #16 was a 90 year-old female admitted to swing bed status on 5/18/10 and died on 5/23/10. On the facility's computer generated Death Notification Form, the nurse noted "Family declined" in the space designated for the name of the Procurement Coordinator. There was no evidence in the medical record that the OPO had been contacted.

Based on record review, facility policy review, and staff interview, the facility failed to collaborate with the OPO to involve family in the decision of organ donation for 2 (#s 10 and 16) of 10 patients reviewed. Findings include:

1. In the facility's policy Organ Procurement under the section labeled Procedure, the policy reads: "In the event that the Procurement Coordinator wishes staff to approach the deceased's family for consent or refusal of donation, it will become the responsibility or [sic] the registered nurse on duty to become the 'Designated Requester' The Designated Requestor must use discretion and sensitivity with respect to the circumstances, views and beliefs of the family of the potential donor." The facility did not have a designated requestor in the facility.

2. During the interviews with nurses J and M on 8/17/10 at 4:10 p.m. and 8/18/10 at 6:56 a.m., the nurses stated that they were not aware of training on the OPO process.

3. On 8/18/10 at 9:55 a.m., the DON stated if the patient had an Advance Directive stating they did not want to donate organs or the patient's family refused to donate the organs on the patient's behalf, the OPO did not need to be called.


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4. Patient #16 was a 90 year-old female admitted to swing bed status on 5/18/10 and died on 5/23/10. On the facility's computer generated Death Notification Form, the nurse noted "Family declined" in the space designated for the name of the Procurement Coordinator. There was no evidence that the OPO had been contacted when this patient died.

5. Patient #10 was a 59 year-old female admitted to swing bed status on 1/6/10 and died on 1/16/10. On the facility's computer generated Death Notification Form, the nurse noted the OPO "coordinator not called for family reasons." There was no evidence in the medical record that the OPO had been contacted.

Based on document review and staff interview, the facility failed to create and implement protocols addressing the education of staff about the donation process. Findings include:

During the review of the facility's policy on Organ Procurement on 8/17/10 at 1:00 p.m., the surveyor could find no evidence that the facility and the OPO had worked cooperatively for the purpose of staff education or review of death records for the purpose of evaluation for the effectiveness of the program.

During the interviews with nurses J and M on 8/17/10 at 4:10 p.m. and 8/18/10 at 6:56 a.m., the nurses stated that they were not aware of training on the OPO process.

On 8/18/10 at 4:30 p.m., the CEO stated he was not aware the OPO would review death records with the facility. The CEO stated he was not aware of the process with the OPO and the facility.






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