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44 NORTH FIRST EAST

PRESTON, ID 83263

No Description Available

Tag No.: C0241

Based on staff interview, review of policies, medical records, and credentials files, it was determined the Governing Body failed to assume responsibility for implementing and monitoring policies governing the CAH's operation. This resulted in a lack of specificity regarding practitioners' duties and qualifications and the failure to develop policies directing patient care. Findings include:

1. The Credentialing Coordinator was interviewed on 9/07/17, beginning at 9:20 AM. She stated the CAH had an orthopedic surgeon, a general surgeon, and an ear, nose, and throat surgeon. The Credentialing Coordinator stated these surgeons visited the hospital 1 or 2 days per week and performed surgeries, including total joint replacements. She stated persons who needed inpatient care following surgery were cared for by family practice physicians.

The credentials files of Physician A and Physician B were reviewed. Both Physician A and Physician B were family practice physicians who were last appointed to the Medical Staff on 11/25/16. Neither physician had privileges to care for the post-surgical patients of the visiting surgeons.

During the above interview, the Credentialing Coordinator confirmed Physicians A and B did not have privileges to care for the above surgical patients.

The Governing Body failed to grant necessary privileges to physicians.

2. The Credentialing Coordinator was interviewed on 9/07/17, beginning at 9:20 AM. She stated the CAH did not have a policy or bylaw that specified which certifications were required for practitioners to treat patients.

Credentials files revealed the following:

a. Physician A was a family practice physician who was last appointed to the Medical Staff on 11/25/16. He had privileges to deliver babies and care for them, including resuscitation if needed. He also had privileges to provide emergency services. He did not have current certifications for ACLS, PALS, and NRP.

b. Physician B was a family practice physician who was last appointed to the Medical Staff on 11/25/16. He had privileges to deliver babies and care for them, including resuscitation if needed. He also had privileges to provide emergency services. He did not have current certifications for ACLS, PALS, and NRP.

c. CRNA C was last appointed to the Medical Staff on 9/24/15. He had privileges to provide anesthesia and life support to adults and children. He also had privileges to resuscitate newborns. He did not have current certifications for ACLS, PALS, and NRP.

d. CRNA D was last appointed to the Medical Staff on 9/24/15. He had privileges to provide anesthesia and life support to adults and children. He also had privileges to resuscitate newborns. He did not have current certification for PALS.

During the above interview, the Credentialing Coordinator confirmed Practitioners A, B, C, and D did not have the above certifications.

The Governing Body failed to specify which certifications were required for practitioners to treat patients.

3. Refer to C271 as it relates to the failure of the Governing Body to ensure policies were developed to define procedures regarding the evaluation of patients in labor.

No Description Available

Tag No.: C0271

Based on staff interview and review of policies and medical records, it was determined the CAH failed to ensure the evaluation of labor was conducted in accordance with appropriate written policies for 2 of 9 patients (#28 and #34) who were evaluated for labor and whose records were reviewed. The failure to develop policies which defined processes resulted in a lack of direction to staff furnishing patient evaluations. Findings include:

1. The policy "MEDICAL/OBSTETRICAL SCREENING EXAMINATIONS UNDER EMTALA," modified 8/12/14, stated "OB patients requesting a 'labor check' or asking to be evaluated for their ability to reach another facility must receive the standard evaluation, unless they refuse evaluation in writing..." The policy did not define what "standard evaluation" meant. For example, the policy did not specifically state what type of monitoring would be used to evaluate labor and for how long.

The policy did not specify the role of the physician or how the physician would document whether the patient was in active labor or having complications. The policy defined a "Qualified Evaluator" as a physician or "A Registered Nurse employee who has Charge Nurse privileges at FCMC who performs medical screening." The policy did not define the role of the physician if the RN performed the evaluation.

The DON was interviewed on 9/08/17 beginning at 9:15 AM. She stated the term "standard evaluation" was not defined in policy. She stated the process was for the physician to write an order or sign the record to document a patient was not in active labor or was safe to transfer. She stated this was not addressed in policy.

The Quality Director was interviewed of 9/08/17, beginning at 10:15 AM. She stated even though the policy stated nurses were given "Charge Nurse Privileges," they were not granted specific privileges to evaluate labor patients by the Governing Body. She stated the CAH was developing a job description to define charge nurse privileges but she said this had not been developed.

The CAH failed to develop policies defining processes for the evaluation of women in labor.

2. Patient #28's medical record stated she was a 31 year old female who presented to the CAH on 8/21/17 at 7:00 PM for "Possible labor." The record stated this was her second pregnancy and she was 35 weeks along. "PATIENT PROGRESS NOTES" by the RN, dated 8/21/17 at 7:00 PM, stated Patient #28 was having contractions every 1 to 3 minutes lasting 60 seconds. "PATIENT PROGRESS NOTES" by the RN, dated 8/21/17 at 7:00 PM, stated Patient #28 was to be discharged from FCMC and see her regular physician at a hospital 68 miles away. There was no documentation by a physician. There was no order to discharge Patient #28. There was no statement that she was not in active labor, by either the physician or the nurse. "PATIENT PROGRESS NOTES" by the RN, dated 8/21/17 at 7:15 PM, stated "FINGERTIP DILATION NOTED ABLE TO TRAVEL AND SEE REGULAR PROVIDER FOR POC PER ON CALL PHYSICIAN." Patient #28's record did not contain documentation of medical decision making.

The RN who cared for Patient #28 was interviewed on 9/07/17 beginning at 4:20 PM. She stated the on-call physician was in the building but did not come to see Patient #28. She stated the physician gave her a verbal order to discharge Patient #28 but she did not write the order.

The CAH failed to evaluate Patient #28's potential labor.

3. Patient #34's medical record stated she was a 21 year old female who presented to the CAH on 2/11/17 at 10:15 PM for "Possible labor." The record stated this was her second pregnancy and she was 37 weeks along. "PATIENT PROGRESS NOTES" by the RN, dated 2/11/17 at 10:20 PM, stated Patient #34 was dilated to 4.5 centimeters and was 50 percent effaced. The note stated Patient #34's contractions started getting "a lot harder" at approximately 5 PM that evening. "PATIENT PROGRESS NOTES" by the RN, dated 2/12/17 at 12:30 AM, stated Patient #34 "...has not changed. Will go home."

Patient #34's record did not contain documentation of medical decision making. There was no documentation by a physician. There was no order to discharge Patient #34. There was no statement that she was not in active labor.

The DON was interviewed on 9/08/17, beginning at 9:15 AM. She stated Patient #34's record did not contain documentation that the patient was stable for discharge.

The CAH failed to evaluate Patient #34's potential labor.

PATIENT CARE POLICIES

Tag No.: C0278

Based on medical record review, observation, CAH policy review, CAH Infection Control Plan review, and staff interview, it was determined the CAH failed to ensure a comprehensive infection control plan was implemented and followed to reduce the risk of infections for 1 of 1 surgical patients (Patient #14) whose care was observed. This had the potential to impact all patients provided care in the CAH. Findings include:

1. Patient #14 was a 4 year old female who was admitted on 9/06/17, for a scheduled tonsillectomy and adenoidectomy.

The CAH's Infection Control Plan, dated 2017, stated "The infection prevention program is based upon nationally recognized guidelines which include: Perioperative Standards and Recommended Practices (AORN)."

A CAH policy "Operating Room Attire," approved 2/16/17, stated "Protective barriers (gloves, masks, protective eyewear, and face shields) are provided by the hospital and should be utilized to reduce the risk of exposure to potentially infective agents."

A second CAH policy "Instruments - Cleaning, Processing, and care of," approved 9/06/17, stated "EQUIPMENT: Protective eye covers." It also stated staff were to don "protective [sic] waterproof gear."

AORN guidelines for perioperative practice, dated 2015, stated "Wearing surgical masks and face and eye protection is recommended by CDC and is a regulatory requirement."

Patient #14's OR circulating RN, CST, and surgeon failed to follow the CAH's Infection Control Plan, CAH policies, and nationally recognized OR guidelines. Examples include:

a. The OR circulating RN was observed preparing Patient #14's OR IV fluids prior to her scheduled surgery on 9/06/17, beginning at 7:15 AM. She was first observed to remove an IV maintenance fluid bag and IV tubing administration set from their respective packaging. The OR circulating RN was then observed to remove the IV tubing's protective spike cover by placing it between her teeth and pulling it off. Following this, she removed the uncovered IV tubing's spike from her mouth and inserted it into the IV maintenance fluid bag.

The IV tubing was attached to Patient #14's PIV at approximately 8:34 AM.

The OR Manager was interviewed on 9/06/17, beginning at 9:27 AM, and Patient #14's surgical care observations were reviewed in his presence. He confirmed the OR circulating RN did not follow AORN guidelines and should not have placed any portion of medical equipment in her mouth. The OR Manager confirmed the OR circulating RN should have prepared the IV tubing and fluids aseptically.

The QI Director, who stated she was responsible for the CAH's Infection Control Plan, was interviewed on 9/06/17, beginning at 9:40 AM, and Patient #14's surgical care observations were reviewed in her presence. She stated the OR circulating RN did not follow the CAH's Infection Control Plan or AORN perioperative practices.

The OR circulating RN failed to follow the CAH's Infection Control Plan and nationally recognized OR guidelines.

b. Patient #14's surgical procedure was observed on 9/06/17, beginning at approximately 8:34 AM. Patient #14's surgeon arrived to the OR suite at 8:41 AM and was observed not wearing a surgical mask. The procedure started at 8:46 AM and concluded at 8:52 AM. The surgeon did not wear a surgical mask for the entirety of the procedure.

The OR Manager was interviewed on 9/06/17, beginning at 9:27 AM, and Patient #14's surgical care observations were reviewed in his presence. He stated the surgeon should have worn a surgical mask during the procedure as outlined in CAH policy, nationally recognized OR guidelines, and the CAH's Infection Control Plan.

The QI Director was interviewed on 9/06/17, beginning at 9:40 AM, and Patient #14's surgical care observations were reviewed in her presence. She stated the surgeon should have worn a surgical mask during the procedure as outlined in CAH policy, nationally recognized OR guidelines, and the CAH's Infection Control Plan.

The surgeon failed to follow CAH policy, the CAH's Infection Control Plan, and nationally recognized OR guidelines.

c. Patient #14's surgical procedure concluded on 9/06/17, at 8:52 AM, and the CST was observed transporting the soiled surgical instruments to the adjacent reprocessing room at that time. Once in the reprocessing room, she transferred all soiled instruments to the designated "dirty" area and proceeded to soak/scrub the equipment while wearing gloves. The CST did not wear protective eye covers or waterproof gear. When asked if she was familiar with the CAH PPE policy regarding instrument reprocessing, the CST stated "oh, I should be wearing my PPE." She then stopped cleaning the equipment, washed her hands, and donned new gloves, apron, and eye protection.

The OR Manager was interviewed on 9/06/17, beginning at 9:27 AM, and Patient #14's surgical care observations were reviewed in his presence. He confirmed the CST should have worn PPE prior to instrument reprocessing.

The QI Director was interviewed on 9/06/17, beginning at 9:40 AM, and Patient #14's surgical care observations were reviewed in her presence. She confirmed the CST should have worn required PPE during instrument reprocessing.

The CST failed to follow CAH policy.

2. The CAH's Infection Control Plan listed the following services under its scope:

"- Medical

- General Surgery

- Emergency

- Obstetrics

- Orthopedics

- Gastroenterology

- Internal Medicine

- Urology

- Pain services

- Pediatrics

- ENT

- Sleep Studies

- Ambulatory Surgery

- Endoscopy

- Lab

- Radiology: MRI, CT Scanner, Ultrasound, Digital Mammography, DEXA scan

- Physical Therapy, Occupational Therapy, Speech Therapy"

The CAH's Infection Control Plan did not include the Respiratory Therapy department.

The Respiratory Therapy Manager was interviewed on 9/07/17, beginning at 2:23 PM, and the CAH's Infection Control Plan was reviewed in his presence. He stated the Respiratory Therapy department was not involved in the CAH's Infection Control Plan, was not invited or attended Infection Control Committee meetings, and he was unsure of which nationally recognized infection control guidelines the Respiratory Therapy department followed.

The QI Director was interviewed on 9/07/17, beginning at 1:30 PM, and the CAH's Infection Control Plan was reviewed in her presence. She confirmed the Respiratory Therapy department was not included in the CAH's Infection Control Plan and did not participate in Infection Control Committee meetings.

The CAH failed to implement an Infection Control Plan which included all patient care service lines.

No Description Available

Tag No.: C0296

Based on medical record review and staff interview, it was determined the CAH failed to ensure an RN evaluated and provided oversight for 3 of 3 inpatients (#9, #13, and #19) who received inpatient LPN nursing care and whose records were reviewed. This lack of RN oversight had the potential for inpatients' conditions to deteriorate without appropriate intervention. Findings include:

1. Patient #19 was a 53 year old female who was admitted on 4/17/17, with a diagnosis of decreased level of consciousness and alcohol withdrawal.

Patient #19 received inpatient LPN nursing care during her admission, however, her medical record did not include documented RN oversight of LPN care provided.

2. Patient #9 was an 84 year old male who was admitted on 4/26/17, with a diagnosis of left foot ulcer.

Patient #9 received inpatient LPN nursing care during his admission, however, his medical record did not include documented RN oversight of LPN care provided.

3. Patient #13 was a 64 year old male who was admitted on 4/13/17, with diagnoses including dehydration and leukocytosis.

Patient #13 received inpatient LPN nursing care during his admission, however, his medical record did not include documented RN oversight of LPN care provided.

The QI Director was interviewed on 9/08/17, beginning at 9:29 AM. When asked if RNs provided documented LPN oversight, she stated no. The QI Director stated LPNs would go to either a floor RN or the Charge RN if they had questions or concerns, but confirmed this practice was not documented.

The CAH failed to ensure RN evaluation of LPN inpatient care.

No Description Available

Tag No.: C0302

Based on medical record review and staff interview, it was determined the CAH failed to ensure 3 of 36 medical records (#15, #28, and #34) included complete and accurate medical record entries. This had the potential to interfere with the coordination and provision of patient care. Findings include:

1. Patient #28's medical record stated she was a 31 year old female who presented to the CAH on 8/21/17 at 7:00 PM for "Possible labor." The record stated this was her second pregnancy and she was 35 weeks along. "PATIENT PROGRESS NOTES" by the RN, dated 8/21/17 at 7:00 PM, stated Patient #28 was having contractions every 1 to 3 minutes lasting 60 seconds. "PATIENT PROGRESS NOTES" by the RN, dated 8/21/17 at 7:00 PM, stated Patient #28 was to be discharged from FCMC and see her regular physician at a hospital 68 miles away. There was no documentation by a physician. There was no order to discharge Patient #28. There was no statement that she was not in active labor, by either the physician or the nurse. "PATIENT PROGRESS NOTES" by the RN, dated 8/21/17 at 7:15 PM, stated "FINGERTIP DILATION NOTED ABLE TO TRAVEL AND SEE REGULAR PROVIDER FOR POC PER ON CALL PHYSICIAN." The documentation did not explain what this meant or why Patient #28 needed to travel to another hospital that night to see a physician there. Patient #28's record did not contain documentation of medical decision making. Patient #28's record did not document that she was stable for discharge. Patient #28's record did not document a rationale for sending the patient to another hospital.

The RN who cared for Patient #28 was interviewed on 9/07/17, beginning at 4:20 PM. She stated the on-call physician was in the building but did not come to see Patient #28. She stated the physician gave her a verbal order to discharge Patient #28, but she did not write the order.

The on-duty Charge Nurse for 9/07/17 was interviewed at 3:30 PM, and Patient #28's record was reviewed in her presence. She stated the documentation was not complete. She also stated the documented time that Patient #28 was admitted was not correct.

Patient #28's medical record was not complete or accurate.

2. Patient #34's medical record stated she was a 21 year old female who presented to the CAH on 2/11/17 at 10:15 PM for "Possible labor." The record stated this was her second pregnancy and she was 37 weeks along. "PATIENT PROGRESS NOTES" by the RN, dated 2/11/17 at 10:20 PM, stated Patient #34 was dilated to 4.5 centimeters and was 50 percent effaced. The note stated Patient #34's contractions started getting "a lot harder" at approximately 5 PM that evening. "PATIENT PROGRESS NOTES" by the RN, dated 2/12/17 at 12:30 AM, stated Patient #34 "...has not changed. Will go home."

Patient #34's record did not contain documentation by a physician. There was no order to discharge Patient #34. There was no statement that she was not in active labor, by either a physician or the nurse. Patient #34's record did not include documentation of medical decision making.

The DON was interviewed on 9/08/17, beginning at 9:15 AM. She stated Patient #34's record did not include documentation of medical decision making. She stated the record did not include documentation that the patient was stable for discharge.

Patient #28's medical record was not complete.



37262

3. Patient #15 was a 46 year old female who was admitted on 5/05/17, for a scheduled exploratory laparoscopy and right oophorectomy.

Patient #15's medical record included a "GYN OUT PATIENT PRE-OP ORDERS," dated 5/05/17, signed by her physician. The order included TED hose and SCDs to be applied to Patient #15 prior to her surgical procedure. Patient #15's medical record also included a "SURGERY FLOW SHEET," dated 5/05/17, signed by the OR circulating RN. The OR circulating RN documented use of TED hose and SCDs were "not applicable." It could not be determined if Patient #15 received her TED hose and SCDs as ordered by her physician.

The DON was interviewed on 9/06/17, beginning at 1:16 PM, and Patient #15's medical record was reviewed in her presence. She confirmed it could not be determined if Patient #15 received her TED hose and SCDs as ordered by her physician.

The CAH failed to ensure Patient #15's medical record was accurate.

No Description Available

Tag No.: C0307

Based on medical record review and staff interview, it was determined the CAH failed to ensure medical record entries were dated, timed, signed, and completed by the MD/DO/other health professional for 2 of 8 patients (#13 and #27) who were transferred to another facility and whose records were reviewed. This resulted in a lack of clarity regarding authentication of medical record entries. Findings include:

1. Patient #27 was a 4 year old male who was treated in the ED on 6/16/17, with a diagnosis of MCA and multiple trauma. He was transferred to an acute care hospital on 6/16/17.

Patient #27's medical record included an "EMTALA TRANSFER/DISCHARGE SHEET," signed by his physician. The EMTALA transfer order was not dated or timed.

The DON was interviewed on 9/08/17, beginning at 8:29 AM, and Patient #27's medical record was reviewed in her presence. She confirmed Patient #27's EMTALA transfer order was not dated or timed by his physician.

The CAH failed to ensure Patient #27's physician medical record entries were dated and timed.



25957

2. Patient #13 was a 63 year old male who was admitted to the facility on 4/13/17 with diagnoses including dehydration and leukocytosis (elevated white blood cell count.) He was transferred to an acute care hospital on 4/18/17.

A document titled "EMTALA TRANSFER/DISCHARGE SHEET," undated, did not indicate if EMTALA applied to Patient #13's transfer. A nurses note, detailing the transfer, was signed and timed, but not dated.

In an interview on 9/7/17 at 4:00 PM, the DON confirmed the lack of clarification related to Patient #13's transfer.

Transfer documentation for Patient #13 was incomplete.

No Description Available

Tag No.: C0322

Based on medical record review and staff interview, it was determined the CAH failed to ensure a documented post-anesthesia evaluation by a qualified practitioner prior to discharge for 4 of 4 surgical outpatients (#14, #15, #16, and #17) whose records were reviewed. This had the potential to interfere with patient safety. Findings include:

1. Patient #14 was a 4 year old female who was admitted on 9/06/17, for a scheduled tonsillectomy and adenoidectomy.

Patient #14's medical record included a "Post Anesthesia Evaluation," dated 9/06/17, signed by the CRNA. The form included sections for vital signs and level of consciousness score at discharge. These 2 sections were left blank.

The DON was interviewed on 9/06/17, beginning at 1:10 PM, and Patient #14's medical record was reviewed in her presence. She confirmed Patient #14 did not have a documented post-anesthesia evaluation prior to discharge.

The CAH failed to ensure Patient #14 had a documented post-anesthesia evaluation by a qualified practitioner prior to discharge.

2. Patient #15 was a 46 year old female who was admitted on 5/05/17, for a scheduled exploratory laparoscopy and right oophorectomy.

Patient #15's medical record included a "Post Anesthesia Evaluation," dated 5/05/17, signed by the CRNA. The form included a section for vital signs. This section was left blank.

The DON was interviewed on 9/06/17, beginning at 1:16 PM, and Patient #15's medical record was reviewed in her presence. She confirmed Patient #15 did not have a documented post-anesthesia evaluation prior to discharge.

The CAH failed to ensure Patient #15 had a documented post-anesthesia evaluation by a qualified practitioner prior to discharge.

3. Patient #16 was a 55 year old male who was admitted on 1/13/17, for a scheduled umbilical hernia repair.

Patient #16's medical record included a "Post Anesthesia Evaluation," undated, signed by the CRNA. The form included sections for vital signs and level of consciousness score at discharge. These 2 sections were left blank.

The DON was interviewed on 9/06/17, beginning at 1:04 PM, and Patient #16's medical record was reviewed in her presence. She confirmed Patient #16 did not have a documented post-anesthesia evaluation prior to discharge.

The CAH failed to ensure Patient #16 had a documented post-anesthesia evaluation by a qualified practitioner prior to discharge.

4. Patient #17 was a 41 year old female who was admitted on 1/23/17, for a scheduled laparoscopic cholecystectomy.

Patient #17's medical record included a "Post Anesthesia Evaluation," dated 1/23/17, signed by the CRNA. The form included sections for vital signs and level of consciousness score at discharge. These 2 sections were left blank.

The DON was interviewed on 9/06/17, beginning at 1:23 PM, and Patient #17's medical record was reviewed in her presence. She confirmed Patient #17 did not have a documented post-anesthesia evaluation prior to discharge.

The CAH failed to ensure Patient #17 had a documented post-anesthesia evaluation by a qualified practitioner prior to discharge.

No Description Available

Tag No.: C0325

Based on medical record review and staff interview, it was determined the CAH failed to ensure patients were discharged in the company of a responsible adult for 4 of 4 surgical outpatients (#14, #15, #16, and #17) whose records were reviewed. This had the potential for poor patient safety outcomes. Findings include:

1. Patient #14 was a 4 year old female who was admitted on 9/06/17, for a scheduled tonsillectomy and adenoidectomy.

Patient #14 medical record included a discharge date of 9/06/17, however, the responsible adult she was discharged in the company of was not documented.

The DON was interviewed on 9/06/17, beginning at 1:10 PM, and Patient #14's medical record was reviewed in her presence. She confirmed Patient #14's discharge in the company of a responsible adult was not documented.

The CAH failed to ensure Patient #14's discharge in the company of a responsible adult was documented.

2. Patient #15 was a 46 year old female who was admitted on 5/05/17, for a scheduled exploratory laparoscopy and right oophorectomy.

Patient #15 medical record included a discharge date of 5/05/17, however, the responsible adult she was discharged in the company of was not documented.

The DON was interviewed on 9/06/17, beginning at 1:16 PM, and Patient #15's medical record was reviewed in her presence. She confirmed Patient #15's discharge in the company of a responsible adult was not documented.

The CAH failed to ensure Patient #15's discharge in the company of a responsible adult was documented.

3. Patient #16 was a 55 year old male who was admitted on 1/13/17, for a scheduled umbilical hernia repair.

Patient #16 medical record included a discharge date of 1/13/17, however, the responsible adult he was discharged in the company of was not documented.

The DON was interviewed on 9/06/17, beginning at 1:04 PM, and Patient #16's medical record was reviewed in her presence. She confirmed Patient #16's discharge in the company of a responsible adult was not documented.

The CAH failed to ensure Patient #16's discharge in the company of a responsible adult was documented.

4. Patient #17 was a 41 year old female who was admitted on 1/23/17, for a scheduled laparoscopic cholecystectomy.

Patient #17 medical record included a discharge date of 1/23/17, however, the responsible adult she was discharged in the company of was not documented.

The DON was interviewed on 9/06/17, beginning at 1:23 PM, and Patient #17's medical record was reviewed in her presence. She confirmed Patient #17's discharge in the company of a responsible adult was not documented.

The CAH failed to ensure Patient #17's discharge in the company of a responsible adult was documented.

No Description Available

Tag No.: C0345

Based on review of medical records, review of facility agreements, and staff interview, it was determined the CAH failed to ensure the Organ Procurement Organization was notified of the deaths of 1 of 2 patients (Patient #9) who expired in the CAH and whose records were reviewed. This resulted in potentially suitable organ, tissue, and eye donors to remain unidentified. Findings include:

An agreement with the regional OPO, dated 1/21/15, defined the responsibilities of the CAH to include "The hospital will notify [name of OPO] in a timely manner of every individual who has died in the hospital."

This agreement was not implemented as follows:

1. Patient #9 was an 84 year old male admitted to the facility on 4/26/17, with a diagnosis of left foot ulcer. He expired on 5/20/17.

Patient #9's record did not include documentation of OPO notification at the time of his death. A document, titled "ORGAN AND TISSUE DONATION NOTIFICATION," was present in Patient #9's record. However, the form indicated only a funeral home had been notified at the time of his death.

In an interview on 9/07/17 at 4:00 PM, the DON confirmed Patient #9's death had not been reported to the OPO.

The CAH failed to implement the death notification process included in an agreement with the regional OPO.