HospitalInspections.org

Based on record review, staff interview, Policy and Procedure review, and facility Agreement review, the facility failed to notify the Organ Procurement Organization (OPO) in a timely manner of individuals whose death was imminent or who had died in the hospital, for six (6) of 270 patient deaths in 2017. One (1) patient in January, one (1) patient in February, two (2) patients in March, one (1) patient in June, and one (1) patient in December

Findings Include:

Review of the facility's "Donation Referral Compliance and Conversion Rates" report for 2017 revealed there were late tissue referrals for one (1) patient in January, one (1) patient in February, two (2) patients in March, one (1) patient in June and one (1) patient in December.

During an interview on May 30, 2018 at 3:55 p.m. the Quality Assurance Coordinator confirmed the facility had been late in calling in six (6) deaths for tissue referrals, to the OPO in 2017.

Review of the facility's "Organ/Tissue Donation/Donation After Cardiopulmonary Death" Policy, last revised 3/3/17, revealed: "Scope- The information in this policy is for use by all medical and nursing staff responsible for the treatment and care of patients that at some point may be an organ/tissue donor or meet criteria for donation after cardiac death. 1. To provide guidelines to identify potential organ, eye, and tissue donors, routinely offer the families of deceased patients the opportunity to authorize organ, eye and/or tissue donation as well as facilitate the organ, eye, and tissue donation process in accordance with state and federal laws, regulatory and accreditation agency requirements. II. Definitions: ...Timely Notification for Tissue Donation-For individuals who have died a cardiac death, notification is timely if the referral is made to the Mississippi Organ Recovery Agency (MORA) within one hour of the cardiac death ...Procedure ...C. Call MORA via the Donor Referral Line (1-800-362-6169) in a timely manner ...3. For individuals who have died a cardiac death, a timely referral is one that is made as soon as possible, within one hour, of the cardiac time of death ...".

Review of the facility's "Organ and Tissue Donation Cooperative Agreement" with MORA, approved by the facility's Chief Executive Officer (CEO), 4/12/12, revealed: " ...III. Responsibilities of Delta Regional Medical Center: ...7. Timely referral of all expired patients, within one hour of cardiac death, to the MORA referral line. MORA shall then be responsible for the evaluation of the patient as a potential tissue donor ...".

Based on record review, staff interview, and Policy and Procedure review, the facility failed to notify the Organ Procurement Organization (OPO) in a timely manner of individuals whose death was imminent or who had died in the hospital, for six (6) of(270 patient deaths in 2017.

Findings Include:

Cross Refer to A0884 for the facility's failure to notify, in a timely manner, the OPO of individuals whose death was imminent or who had died in the hospital.