HospitalInspections.org

Based on record review and interview, the facility failed to obtain regular fire safety inspections and approval from local fire officials of their fire plan.

The findings are:

During review of the facility comprehensive emergency plan, it was noted that the most recent review and approval of the the fire plan was on 8/14/09. No record of fire safety inspections by local or state fire agencies were found.
On 10/27/10 at 4:15 PM, the maintenance director stated that the last review and approval of the fire plan was on 8/14/09 as noted. I have place multiple calls to the fire chief about getting the plan reviewed but have not gotten a response.

Based on interview and record review, it was determined the hospital failed to ensure that the organ procurement requirements are met. The hospital failed to ensure policies and procedures addressing it's organ procurement responsibilities were written and implemented (A 0885 - Standard). The hospital failed to incorporate an agreement with an Organ Procurement Organization (OPO) addressing the required information (A 0886 - Standard).
The hospital failed to ensure that the families of each potential organ donor were informed of their option to donate organs (A 0888 - Standard). The findings are:

During interview on 10/26/10 at approximately 2:45 PM, the Director of Nursing (DON) informed the surveyor that the hospital currently did not have the potential to and was not participating in an organ procurement program. She further explained that there are no ventilators being used by the hospital and therefore, no means to keep donated organs viable until they could be harvested.

Based on interview and record review, the hospital failed to ensure policies and procedures addressing it's organ procurement responsibilities were written and implemented. The findings are:

Review of facility policy number 606-020, titled, "Tissue Donation Guidelines," revealed no evidence of the policy addressing organ donation. The policy was directed toward the procurement and donation of tissue with a Statement of Purpose which read, "To delineate the guidelines for staff participating in tissue donation procedures," and the definition for Tissue Donation only. The policy also included Expected Outcomes and information related to Potential Tissue Only Donors which addressed policy and procedures relating to tissue donation only. The policy failed to include information addressing organ procurement responsibilities.

During interview on 10/26/10 at approximately 2:45 PM, the Director of Nursing (DON), confirmed the facility had no further policy regarding addressing organ procurement. The DON informed the surveyor that the hospital currently did not have the potential to and was not participating in an organ procurement program. She further explained that there are no ventilators being used by the hospital and therefore, no means to keep donated organs viable until they could be harvested.

Based on interview and record review, the hospital failed to incorporate an agreement with an Organ Procurement Organization (OPO) addressing the required information. The findings are:

Upon request for a copy of the hospital's Organ Procurement Agreement with the OPO, facility staff provided the surveyor with a document titled, "Life Quest Organ Recovery Services - 2010 Hospital Services Goals." The document, which was signed by both the hospital's Director of Nursing and the Hospital Services Coordinator for Life Quest Organ Recovery Services and dated 03/02/2010, contained the following: 1. Maintain Communication and Awareness with Hospital Staff. Communicate with (DON), to assess for any changes in hospital potential. (Presently no ventilators utilized in the hospital); and 2. Assess hospital needs on a yearly basis.

The document identified as the hospital's OPO Agreement revealed no information addressing the following: criteria for referral; definitions of imminent death and timely notification; the OPO's responsibility to determine medical suitability for organ donation; provisions for notification of each individual death to the OPO in a timely manner; assurance that the designated requestor training program offered by the OPO has been developed in cooperation with the tissue bank and eye bank designated by the hospital; permission for the OPO to access the hospital's death record information according to a designated schedule, e.g., monthly or quarterly; a statement indicating that the hospital is not required to perform credentialing reviews for, or grant privileges to, members of organ recovery teams as long as the OPO sends only "qualified, trained individuals" to perform organ recovery; and, the interventions the hospital will utilize to maintain potential organ donor patients so that the patient organs remain viable.

During interview on 10/26/10 at approximately 2:45 PM, the Director of Nursing (DON), confirmed the facility's agreement with the OPO did not contain the required information. The DON informed the surveyor that the hospital currently did not have the potential to and was not participating in an organ procurement program. She further explained that there are no ventilators being used by the hospital and therefore, no means to keep donated organs viable until they could be harvested.

Based on interview with facility staff, the hospital failed to ensure that the families of each potential organ donor were informed of their option to donate organs. The findings are:

During interview on 10/26/10 at approximately 2:45 PM, the Director of Nursing (DON) informed the surveyor that the hospital currently did not have the potential to and was not participating in an organ procurement program. She further explained that there are no ventilators being used by the hospital and therefore, no means to keep donated organs viable until they could be harvested. At the current time, the facility is failing to ensure that the families of each potential organ donor are being informed of their option to donate organs.