HospitalInspections.org

Based on document review, staff interview, and Policy and Procedure review, the facility failed to notify the Organ Procurement Organization (OPO) in a timely manner of individuals whose death was imminent or who had died in the hospital, for two (2) out of 12 months of 2017. (One (1) patient in February and 1 patient in July).

Findings Include:

Review of the facility's "Donation Referral Compliance and Conversion Rates" report from the OPO for the year 2017 revealed: One patient death was approximately three (3) hours late being called in to the OPO as a tissue referral in February of 2017 and there was one missed organ referral on a patient who met the triggers for organ referral (Glasgow Coma Scale (GCS) of five (5) or less, on the ventilator, neurological insult) in July of 2017.

During an interview on January 4, 2017 at 10:30 a.m. the Director of Quality confirmed the facility had been late in calling in one death for a tissue referral to the OPO, in February of 2017 and had one missed organ referral in July of 2017.

Review of the facility's "Organ and Tissue Donation After Death" policy and procedure, last revised 7/1/17, revealed: " ...Purpose: To provide guidelines for organ/tissue donation and define the roles of the Hospital and Organ Procurement Organization (OPO). Policy Statement:..2. The hospital will notify OPO when a patient meets referral criteria ...Procedure: ...On or before the occurrence of each death, the hospital will: 1. It is the obligation of the patient's nurse or designee to contact OPO within one hour of a patient first meeting one of the following: Ventilated patient with a GCS score of less than or equal to 5 ...After death. Imminent Death: Patient who requires mechanical ventilation; is in an Intensive Care Unit, has clinical findings consistent with a Glasgow Coma Score that is less than or equal to 5 ...4. The hospital will be responsible for contacting the OPO ...".

Based on document review, staff interview, and Policy and Procedure review, the facility failed to notify the Organ Procurement Organization (OPO) in a timely manner of individuals whose death was imminent or who had died in the hospital, for two (2) out of 12 months of 2017. (February and July)

Findings Include:

Cross Refer to A-0884 for the facility's failure to notify the OPO in a timely manner of individuals whose death was imminent or who had died in the hospital. One (1) patient in February 2017 and 1 patient in July 2017.