HospitalInspections.org

Based on record review, staff interview and policy and procedure review, the facility failed to notify, in a timely manner, the Organ Procurement Organization (OPO) or a third party designated by the OPO of individuals whose death is imminent or who have died in the Critical Access Hospital (CAH) for two (2) out of 25 patient deaths during the last 12 months. One (1) patient in April of 2018 and one (1) patient in December 2018 was not called in.

Findings Include:

Review of the facility's "MORA 2018 Tissue Donation Report" and the "MORA 2018 Tissue Donation Report" revealed, one (1) patient in April of 2018 and one (1) patient in December 2018 death was not called in an timely manner.

During an interview on 01/07/19 at 2:15 p.m, the Director of Nursing (DON) confirmed both patients' death was not called in a timely manner. He stated the April 2018 death was one (1) minute late and the December death was an hour late. In addition, he states he has called MORA and they provided in-service for all his nursing staff.

Review of the facility's "Organ and Tissue Donation Cooperative Agreement Between Mississippi Organ Recovery Agency and (hospital)" revealed: " ...Timely Notification for Organ Donation: A timely referral is one that is made as soon as possible (ideally within one (1) hour) and allows MORA to evaluate and determine eligibility for organ donation potential for any severely brain-injured or brain dead patient prior to the withdrawal of the ventilator and/or care ....Timely Notification for Tissue Donation: For individuals who have died a cardiac death, notification is timely if the referral is make as soon as possible, ideally within one (1) hour of the cardiac death ...".