HospitalInspections.org

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Based on interview, policy review and record review, the facility failed to ensure the organ procurement organization (OPO) was contacted in two of four patients' (Patient #3 and Patient #13) records reviewed of deceased patients. This failure could prevent the donation of organs to increase the quality and/or length of a person in need.

Findings:

1. Review of Patient #3's electronic medical record (EMR) showed an arrival to the Emergency Department (ED) on 8/24/21 at 8:32 am, unresponsive via Emergency Medical Services (EMS). Patient #3 was in respiratory failure and was pronounced deceased at 9:12 AM.

Review of Patient #3's EMR "Notes" tab showed the death declaration and that the Medical Examiner was contacted, however, no documentation was found that the OPO was contacted regarding potential donation.

2. Review of Patient #13's EMR showed an ED arrival via EMS in cardiac arrest with cardiopulmonary resuscitation ongoing on 12/21/20 at 2:10 AM. Resuscitation attempts continued in the ED unsuccessfully and Patient #13's was pronounced deceased at 2:28 AM.

Review of Patient #13's EMR "Notes" tab showed the death declaration and that the Medical Examiner was contacted, however, no documentation was found that the OPO was contacted regarding potential donation.

During an interview on 11/17/21 at 2:58 PM, the Chief Nursing Officer confirmed the OPO was not contacted and stated, "Staff is not quite in sync with the policy on when they are supposed to call [the OPO]."

Review of the facility's policy titled "Deaths (Inpatient)," last reviewed 3/2019, showed:
" ...Procedure ...
4. All patients between the ages of birth to 80 years may be reviewed for possible donation. Patient/resident or family members should only be approached regarding organ/tissue donation by the procurement agency. Call Life Alaska Donor Services [phone number] to report ALL deaths in the Acute setting ..."
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Based on interview, and review of the facility's "Emergency Preparedness Communication Plan," the Critical Access Hospital (CAH) failed to identify a method of communication with the authority having jurisdiction in cases of emergency to provide information regarding the CAH's occupancy, facility needs, and ability to provide emergency assistance during a disaster or emergency. The CAH's failure to identify the means of communication with the authority having jurisdiction, had the potential to affect the two patients receiving care in the facility, and to hinder the facility's ability to keep patients safe, and to render assistance during an emergency event.

Findings:

Review of the facility's "Emergency Preparedness Plan (EPP) Communication Plan" on 11/17/21 at 2:00 PM showed the plan did not include a method for providing information about the facility's occupancy, current needs, and any ability to provide assistance to the authority having jurisdiction, or to the Incident Command Center, or designee in the event of an emergency.

In an interview on 11/17/21 at 3:04 PM, the Emergency Operations Coordinator (EOC) was able to verbalize a process, however, stated. "I don't think we have anything like that in there [EPP]."
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