HospitalInspections.org

Based on interview and record review, the facility failed to ensure their organ, tissue, and eye donation program (OPO) was integrated into their facility's Quality Assurance and Performance Improvement Program (QAPI). This deficient practice had the potential to affect all patients with a requested organ donor and imminent death. Findings include:

During an interview and record review on 1/17/24 at 1:20 p.m., staff member G stated the facility's OPO program was not currently included into their QAPI, and they did not have a "score card" for it.

A review of the facility's QAPI minutes showed no documentation for the inclusion of the OPO program.

Based on interview and record review, the facility failed to follow their established policies and procedures to provide on-going training to a contracted employee on the prohibition and prevention of patient abuse. This deficient practice had the potential to affect all facility contracted staff and those patients whom they provided care. Findings include:

Review of the facility's policy and procedure titled, Annual Refresher Training, last reviewed on 4/28/23, showed:

- "Policy:
It is the policy of [Facility] to have annual refresher training be an essential part of our plan to provide a safe workplace at [Facility]. Job specific safety training and facility wide safety training will be provided to employees through various platforms..."

Review of the facility's employee personnel files for staff member C did not show evidence of annual or additional sessions on abuse training.

During an interview on 1/18/24 at 9:40 a.m., staff member GG stated staff member C was a contracted employee and they did not have an annual refresher training for abuse prohibition on file for staff member C.