HospitalInspections.org

Based on the Life Safety Code portion of the survey, the facility was found not in compliance with the Condition of Participation found at CFR 482.41 (b).

Refer to Life Safety Code deficiencies - K29, K33, K62, and K106 for additional information.

Based on interview and documentation review the hospital did not ensure 6 of 18 patient care staff (OT-A, PT-B, SLP-C, SLP-D, OT-E, PT-F ) reviewed for organ procurement (OPO) training received the OPO training.

Findings include:

Review of the hospital personnel training records indicated Occupational therapist (OT-A, OT-E), Physical therapist (PT-B, PT-F) and Speech therapist (ST-C, SP-D) did not receive training on OPO requirements.

OT-A was hired on 4/17/89, and had not received any OPO training since date of hire.
PT-B was hired on 6/29/07, and had not received any OPO training since date of hire.
ST-C was hired on 4/9/11, and had not received any OPO training since date of hire.
ST-D was hired on 11/1/82, and had not received any OPO training since date of hire.
OT-E was hired on 4/18/11, and had not received any OPO training since date of hire.
PT-F was hired on 11/27/12, and had not received any OPO training since date of hire.

Interview with the hospital director of patient safety at 1:35 a.m. on 7/17/13, indicated the hospital only trains registered nurses and nurse practitioners regarding OPO. She confirmed that Speech, Occupational and Physical therapists are not trained in OPO, but do give direct patient care.