HospitalInspections.org

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on review of 25 emergency room records, the emergency room physicians failed to document the time of the first assessment of patients presenting to the Emergency Room. This affected 22 of 25 emergency room medical records.

Findings include:

The following medical records did not have a documented time the physician first assessed the following patients: Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5, PI # 6, PI # 7, PI # 8, PI # 9, PI # 10, PI # 11, PI # 12, PI # 13, PI # 14, PI # 15, PI # 17, PI # 18, PI # 19, PI # 20, PI # 22, PI # 23, and PI # 25.

Based on medical record review and interviews it was determined Employee Identifier (EI)# 1, the Registered Nurse (RN) initiated the request for organ procurement in 1 of 3 records with Routine Referral Donor Forms, EI#1 had not been formally trained in the donation process.

Findings include:

1. Medical Record (MR) # 1 was admitted to the hospital on 1/16/11 with diagnoses to include Cardiomyopathy. The patient's condition declined and the patient expired on 1/16/11. The Routine Referral Donor Form documented EI# 1 as the employee who completed the form. EI# 1 was not on the designated requestor list provided to the surveyors. The Routine Referral Donor Form contained documentation the family was approached about organ donation by EI# 1 and the Alabama Organ Center was informed of the death by EI# 1.

During an interview with EI#2, the Director of Nursing, on 2/16/11 at 12:50 PM, EI# 2 verified EI# 1 was not trained to be a designated requester for Organ Donations

During an interview with EI# 1 on 2/16/11 at 1:00 PM, EI#1 verified he had not been trained to be a designated requester for Organ Donations.