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Based on medical record (MR) review, document review and interview, the Governing Body (GB) failed to provide oversight of its Organ, Tissue, and Eye Procurement services.

Findings:

The facility's "By-Laws," last amended 10/31/2019 stated, "The board shall, at least annually, assess the performance of the Quality Assurance/Performance Improvement [QAPI] Committee in fulfilling the governing body's quality assurance responsibilities...Board members may also discuss quality assurance/performance improvement issues or problems concerning HHC [Health and Hospitals Corporation] facilities at any meeting of the Board..."

Review of Patient #1's MR identified the following information: The identity of Patient #1 was unknown when the patient was pronounced dead on 5/9/2022 at 3:33PM. On 5/12/2022 at 5:02PM, the Chief Executive Officer (CEO) signed a consent form the Organ Procurement Organization (OPO), a contracted service, provided to the facility, titled "Authorization for Organs and Tissue Donation - English," for the donation of "General Gifts," which stated as follows: "General research provision: If the gifts cannot be used for transplantation or therapy, I authorize their use for research and education purposes."

A Social Work Note, dated 5/13/2022 at 4:20PM, stated that Patient #1's belongings were thoroughly searched; a name, written on a piece of paper, was found in the patient's belongings; and that the search conducted to determine the patient's identity was unsuccessful. A SW Note dated 5/13/2022 at 6:00PM indicated that Patient #1's body was transported to another hospital for organ donation.

The facility failed to identify an unknown/unidentified patient prior to authorizing administrative consent for organ procurement.

During interview of Staff D (Chief Quality Officer) on 9/1/2023 at approximately 3:30PM, Staff D stated that Patient #1's family arrived at the facility on 5/19/2022 and requested an explanation regarding who had authorized Patient #1's organ donation. Staff D stated that the facility conducted meetings with the Chief Medical Officer, Director of Social Work, and Director of Hospital on 5/23/2022, to discuss the steps taken to identify Patient #1 and the limitations of the search process for identifying unknown patients.

Upon request, the facility could not furnish documented evidence of the outcome of their 5/19/2022 or 5/23/2022 family meetings.

The facility's "Consent to An Anatomical Gift: Request for Organ & Tissue Donation," policy was revised on 12/2022, and the "Unidentified Patients and Reports of Missing Persons" policy was revised in 03/2023.

Neither the facility's QAPI Meeting Minutes dated from 6/2022 - 6/2023, nor the facility's GB Meeting Minutes, dated from 12/2022 - 3/2023, contained documented evidence that the GB assessed the services furnished by hospital staff or the OPO, to identify quality and performance problems, implement sufficient corrective measures, and ensure the monitoring and sustainability of those corrective measures.

These findings were confirmed with Staff D (Chief Quality Officer) on 9/2/2023 at approximately 11:15AM.

Based on medical record (MR) review, document review, and interview, the facility failed to maintain an effective, hospital-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program to identify unknown patients.

Findings:

- The facility failed to monitor, track, and analyze data for the patient identification procedures of unidentified/unknown patients.
(See Tag A-0286)

Based on medical record (MR) review, document review, and interview, the facility failed to monitor, track, and analyze data from the patient identification procedures of unidentified/unknown patients.

Findings:

The facility policy and procedure (P&P) titled, "Reporting, Investigating and Response of Occurrences and Sentinel Events," last revised 9/17/2021 stated, "This policy and procedure is intended to continually improve the quality of patient care by ensuring that adverse occurrences are investigated and tracked; that conditions, practices, or behaviors that lead to unfavorable outcomes are corrected; and these corrective actions are regularly monitored for compliance."

The facility P&P titled, "Unidentified Patients," last reviewed 04/2018 stated, "When a patient presents to the Emergency Department and is unable to give his/her name, an attempt will be made to search the property for identifying information (driver's license, social security card, etc.)."

Review of Patient #1's MR identified the following information: The identity of Patient #1 was unknown when this patient was admitted to the facility on 5/7/2022. Hospital Security obtained Patient #1's fingerprints on 5/9/2022 at 10:45AM. Patient #1 was declared brain dead on 5/9/2022 at 3:33PM. A fingerprint search, performed by the New York Police Department (NYPD) on 5/9/2022 to determine the patient's identity, resulted unsuccessful on 5/10/2022. On 5/12/2022 at 5:02PM, Staff E (Chief Executive Officer) signed an administrative "Consent to Anatomical Gift" for Patient #1 for organ and tissue donation.

A Social Work (SW) Note, dated 5/13/2022 at 4:20PM, stated that Patient #1's belongings were thoroughly searched and a name, written on a piece of paper, was found in the Patient #1's belongings. A SW Note dated 5/13/2022 at 6:00PM, stated that Patient #1's body was transported to another hospital for organ procurement.

The facility failed to perform a search of Patient #1's belongings for identifying information prior to authorizing administrative consent for organ procurement.

Per interview of Staff C (Associate Director of Social Work) on 8/31/2023 at 12:30PM, Staff C stated that on 5/19/2022, a NYPD officer called to notify the facility that Patient #1's identity had been confirmed with Patient #1's son.

During interview of Staff D (Chief Quality Officer) on 9/1/2023 at 11:45AM, Staff D stated that Patient #1's family had contacted the hospital on 5/19/2022 to inquire who had authorized the donation of Patient #1's organs.

Review of the facility's Unknown/Unidentified Patient List, generated for dates 9/1/2021 to 9/15/2023, showed over 1800 patients whose identities were unknown at the time of triage. Over 750 patients remained unidentified at the time of their discharge disposition. Over 70 patients had a deceased discharge disposition. A total of nine (9) patients were deceased and remained unidentified at the time of discharge. Of six (6) unidentified deceased patients reviewed, five (5) were referred for organ donation (Patient #s: 1, 2, 3, 6, and 7) although organs were not procured for Patient #s: 2, 3, 6 and 7.

The document titled "Social Work Inpatient Staff Meeting," reviewed on 9/5/2023, identified that on 5/19/2022, the SW Department conducted a Webex training on the search procedures of patients' belongings for SW staff.

During interview of Staff D (Chief Quality Officer) on 9/1/2023 at approximately 11:45AM, Staff D stated that on 5/23/2022, a meeting was held to investigate the process followed and the steps taken to identify Patient #1. Staff D also stated that Risk Management, the Legal Department, and the Chief of the Ethics Committee were involved in the development of corrective actions for this incident.

Upon request, the facility could not furnish documented evidence of this meeting/investigation nor its findings in the facility's QAPI Meeting Minutes.

The "Consent to An Anatomical Gift: Request for Organ & Tissue Donation" policy was revised on 12/2022, and the "Unidentified Patients and Reports of Missing Persons" policy was revised on 03/2023.

Upon request, the facility could not furnish documented evidence the facility staff were re-educated to the revised policies.

The QAPI Meeting Minutes, dated from 06/2022 to 06/2023, identified no documented evidence that this adverse event was identified, investigated, nor discussed during QAPI meetings.

The Organ Donor Council Committee Meeting Minutes, dated from 07/2022 to 07/2023, identified no documented evidence that the committee tracked and analyzed data for unknown/unidentified deceased patients, and the search procedures performed to identify unknown deceased patients.

Upon request, the facility could not furnish documented evidence that this adverse occurrence was investigated and tracked; conditions, practices or behaviors corrected; and that corrective actions, such as the policy revisions or staff re-education, were monitored for compliance in the QAPI meeting minutes.

During interview of Staff D (Chief Quality Officer) on 9/1/2023 at 3:30PM, Staff D confirmed these findings. Staff D stated that in meetings, the facility's administrative staff discussed the identification process conducted for Patient #1 and her next of kin (NOK), and the process for administrative consent for organ donation, but that this information was not documented in the facility's QAPI meeting minutes. Staff D confirmed a root cause analysis was not performed.

Based on medical record (MR) review, document review, and interview, the facility failed to ensure organ, tissue, and eye procurement requirements were met.

Findings:

The facility failed to:

- Institute procedures to timely assist with identifying unidentified patients prior to organ donation referrals.
(See Tag A-0885).

- Ensure staff were re-educated on revised facility policies.
(See Tag A-0891).

Based on medical record (MR) review, document review and interview, in four (4) of 21 MRs, the facility failed to institute procedures to timely assist with identifying unidentified patients prior to organ donation referrals. This was evident in the MRs of Patient #s 1, 2, 3 and 4.

Findings:

The facility policy and procedure (P&P) titled, "Unidentified Patients," last reviewed 04/2018 stated: "The Social Worker on each unit will be responsible for reaching out to the patient to ascertain the true identity of the patient. The Admitting Department will inform the facility's Director of Hospital Police (or designee) of unidentified patient. The Director of Hospital Police will notify the Desk Sergeant of the New York City Police Department [NYPD] precinct wherein the patient was found and transported to the hospital. The precinct will complete an "AIDED REPORT" and assign an "AIDED CASE NUMBER." The precinct station number and the "AIDED CASE" number shall be entered on the "Request for Police Investigation of Unknown Admitted Patient" form. Hospital Police will maintain the "Unknown Patient Tracking Form (HHC 1821) ...If all reasonable efforts to identify the patient prove unsuccessful, upon notification by the [NYPD], the Chief Executive Officer (or designee from Public Affairs Office), shall explore the use of public channels for attempting to identify the patient ..."

The policy also stated, "When a patient presents to the Emergency Department and is unable to give his/her name, an attempt will be made to search the property for identifying information (driver's license, social security card, etc.)."

Review of Patient #1's MR identified that on 5/7/2022 at 7:36PM, Patient #1 was brought to the Emergency Department (ED) by ambulance. Patient #1 arrived unresponsive, with reflexive and labored gasping and breathing, and life-threatening injuries. The injuries included brain bleeding in multiple areas; skull, rib and spine fractures; internal and external lacerations; and partial amputation of a leg. Patient#1's identity was unknown upon arrival to the ED.

During interview of Staff B (ED Social Worker) on 8/31/2023 at 4:15PM, Staff B confirmed a patient's belongings search for Patient #1 was not performed in the ED. Staff B stated that they generally look through the chart and call the Missing Persons Bureau to determine the identity of unidentified patients. Staff B stated that a lot of times, medical and nursing staff look through the belongings of unidentified patients. Staff B stated if the search "was not documented in my notes, it was not done."

Patient #1's fingerprints were collected by hospital security staff on 5/9/2022 and a fingerprint search was performed by the New York City Police Department (NYPD) on 5/9/2022 to determine Patient #1's identity. The fingerprint search resulted unsuccessful on 5/10/2022.

An Inpatient SW Note, dated 5/9/2022 at 11:27AM, stated, "No identifying information or contacts on file for patient. Case escalated to the SW Director. Currently in the process of obtaining patient's fingerprints. The SW spoke with a detective from Missing Persons. No contacts were found. Continue to follow-up as needed."

Patient #1's condition deteriorated, and the patient was declared brain dead on 5/9/2022 at 3:33PM.

On 5/12/2022 at 5:02PM, Staff E (Chief Executive Officer) signed an administrative consent on the form titled, "Authorization for Organs and Tissue Donation - English," for Patient #1.

Per interview of Staff E on 8/31/2023 at 3:05PM, Staff E confirmed they signed an organ procurement organization (OPO) form for the donation of "general gifts." Staff E consented, "If the gifts cannot be used for transplantation or therapy, I authorize their use for research and education purposes."

A SW Note, dated 5/13/2022 at 4:20PM indicated that a thorough search was performed of Patient #1's belongings. The search uncovered a hotel rewards card and a paper with a name written on it. The SW contacted the hotel, but they were unable to provide identifying information. The name on the paper was provided to Missing Persons but no identifying information was received. A social media search was conducted and the assigned detective was informed of the name on the paper. Fingerprints did not return any results.

A SW Note dated 5/13/2022 at 6:00PM stated that Patient #1's body was transported to another hospital for organ procurement.

There was no documented evidence that facility staff searched Patient #1's belongings prior to 5/13/2022.

During interview of Staff C (Associate Director of SW) on 8/31/2023 at 12:30PM, Staff C stated that it was the role of the SW to search for the identity of all patients whose identity was unknown. Staff C also stated Staff B should have searched the patient's belongings while the patient was in the ED.

During interview of Staff A (Deputy Director of Nursing) on 9/1/2023 at 12:25PM, Staff A stated that it was the Patient Care Associates' (PCA) role to search unidentified patients' belongings and provide identifying information to the registered nurse (RN), clerk and social worker (SW) if necessary. Staff A stated that once the patient was stabilized, nursing staff could go through the patient's property and work with a SW to help identify the patient. As per Staff A, this was the practice before and after 05/2022.

There was no documented evidence the Admitting Department informed the facility's Director of Hospital Police (or designee) of the unidentified patient. There was no documented evidence the Director of Hospital Police notified the Desk Sergeant of the New York City Police Department precinct wherein the patient was found and transported to the hospital. There was no documented evidence that the Hospital Police completed the "Unknown Patient Tracking Form" (HHC 1821) and tracked the precinct's "AIDED REPORT." There was no documented evidence the facility explored the use of all public channels to identify Patient #1.

The facility failed to follow its policy to conduct a timely search of Patient #1's belongings for identifying information prior to authorizing an administrative organ donation consent.

Review of Patient #2's MR identified the following information: A Triage Note dated 2/19/2022 at 3:20PM stated that Patient #2 was hypothermic [with low body temperature] on arrival to the ED. Return of heart rate was obtained with ED efforts, and Patient #2 was transferred to the Medical Intensive Care Unit for further treatment. A Physician's Note dated 2/19/2022 at 4:31AM stated that Patient #2's belongings were reviewed, and that staff did not locate any identifying documents, contacts, or information. Patient #2's condition deteriorated, and the patient was pronounced dead on 2/20/2022 at 4:31AM. A Nurse Progress Note, dated 2/20/2022 at 4:50AM, stated that the OPO was notified for potential organ donation.

There was no other documented evidence that additional steps were taken to identify Patient #2.

Review of Patient #3's MR identified the following information: This unidentified patient presented to the ED in cardiopulmonary arrest without any signs of life on 8/14/2023. A Triage Note at 1:37AM identified Patient #3 was found face down on the sidewalk prior to arrival. Advanced Cardiac Life Support measures were started by EMS. Patient #3 was unresponsive to resuscitative measures and was pronounced dead at 1:44AM. A Nursing Note at 2:35AM stated that the OPO was contacted, and that Patient #3 had "no valuables, property, or identifiable information on self. Next of kin and identification will be attempted to be discovered by treatment team."

There was no other documented evidence that additional steps were taken to identify Patient #3.

Review of Patient #4's MR identified the following: This unidentified patient arrived to the ED on 2/10/2023 in cardiac arrest, intubated, and with CPR in progress. Patient #4 was stabilized and transferred to the MICU. A SW Note dated 2/13/2023 at 1:48PM stated that Patient #4's belongings were searched, and no identification was found. The patient's condition deteriorated, and Patient #4 was pronounced dead on 2/14/2023 at 5:58AM.

A facility "Incident Report," dated 9/20/2023 at 8:28PM, identified that a SW requested fingerprints for Patient #4 on 2/13/2023 at 11:44AM. The facility failed to timely collect Patient #4's fingerprints before the patient expired.

These findings were confirmed with Staff D (Chief Quality Officer) on 9/6/2023 at 3:15PM.

Based on document review and interview, the facility failed to ensure staff were re-educated on revised facility policies.

Findings:

The facility policy and procedure (P&P) titled, "Unidentified Patients", last reviewed 04/2018 stated: "The Social Worker on each unit will be responsible for reaching out to the patient to ascertain the true identity of the patient ...The Admitting Department will inform the facility's Director of Hospital Police (or designee) of unidentified patients. The Director of Hospital Police will notify the Desk Sergeant of the New York City Police Department precinct wherein the patient was found and transported to the hospital. The precinct will complete an 'AIDED REPORT' and assign an 'AIDED CASE NUMBER.' The precinct station number and 'AIDED CASE' number shall be entered on the "request for Police Investigation of Unknown Admitted Patient" form. Hospital Police will maintain the "Unknown Patient Tracking Form (HHC 1821) ...If all reasonable efforts to identify the patient prove unsuccessful, upon notification by the New York City Police Department, the Chief Executive Officer (or designee from Public Affairs Office), shall explore the use of public channels for attempting to identify the patient."

The facility reviewed its Unidentified Patients P&P on 05/2022 and re-educated Social Workers on how to conduct a search of an unidentified patient on 5/19/2022, prior to revising the Unidentified Patients P&P on 3/2023.

The revised P&P titled, "Unidentified Patients And Reports of Missing Persons," dated 3/2023 stated the responsible departments for this revised policy were Admitting, Social Work, Hospital Police, and Health Information Management. The Admitting department no longer had the role to notify the hospital police, and the hospital police no longer had a role to notify the New York City Police Department and request an investigation of an unknown patient. The revised policy stated a social worker was now responsible for all aspects of the search to identify unknown patients, including notifying New York City Police Department and missing persons.

Upon request, the facility could not furnish any documented evidence that facility staff, including the Admitting Department, Hospital Police Department, Social Workers, and Health Information Management staff had been re-educated to the revised policy for patient identification after the policy was revised in 03/2023.

The facility P&P titled, "Consent To An Anatomical Gift: Request For Organ & Tissue Donation," was revised in 12/2022.

There was no documented evidence that facility staff were re-educated on this revised policy.

These findings were confirmed with Staff P (Associate Director of Regulatory Affairs) on 10/4/2023 at 3:30PM.