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The facility failed to protect and promote the rights of it's patients. The facility:

Failed to use the least restrictive intervention to protect the patient from harm. See A164;
Failed to obtain an order from the physician who was responsible for patient care. See A168;
Failed to discontinued restraints at the earliest possible time, regardless of the length of time identified in the order. See A174;
Failed to have a physician monitor a patient who was placed in restraints. See A175

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based on observation, interview and policy and procedure review, it was determined that the facility failed to identify, report, investigate, and control infections and communicable diseases of patients and personnel. See tag A749.

Based on record review and interview, the facility failed to record the need for the use of a restraint and failed to explore the least restrictive intervention short of restraint prior to and during the use of restraints for 1 of 3 patients restrained (patient #44). Findings include:

The policy titled "Restraints" was reviewed on 2/15/11. It states, "...it is the responsibility of the staff to continue to seek appropriate alternatives to the restraint. " and "Assessments-an assessment will be performed by a qualified nurse anytime a situation arises of at the time of admission. Medical/Surgical restraints orders need to include date, time, reason for the restraints, and the duration."

On 02/16/11 at approximately 1445 during record review of patient #44 ' s record revealed that the patient was admitted on 09/24/10. Documentation supports that the restraints were on when the patient came by ambulance. Review of the document titled " Orders for Medical/Surgical Restraints" revealed that both Right and Left upper limb restraints were started at 1330 per Registered Nurse initiation of the order. There was no documentation why upon admission that the patient still needs the restraints. The Registered nurse did not document any other interventions that would determine that the patient still needed bi-lateral restraints. The physician signed the order on 09/25/10. There was no documentation from the physician why the patient needed restraints.

On 09/25/10 the Registered Nurse received a phone order on 09/25/10 at 0000. The order did not contain the name of the physician who gave the order. The Registered nurse did not document any other interventions that would determine that the patient still needed bi-lateral restraints. There was no documentation from the physician why the patient needed restraints.

On 09/26/10 the Registered Nurse received a phone order on 09/26/10 at 0000. The order did not contain the name of the physician who gave the order. The Registered nurse did not document any other interventions that would determine that the patient still needed bi-lateral restraints. There was no documentation from the physician why the patient needed restraints.

On 09/27/10 the Registered Nurse received a phone order on 09/27/10 at 0000. The order did not contain the name of the physician who gave the order. The Registered nurse did not document any other interventions that would determine that the patient still needed bi-lateral restraints. There was no documentation from the physician why the patient needed restraints.

On 09/28/10 the Registered Nurse received a phone order on 09/28/10 at 0000. The order did not contain the name of the physician who gave the order. The Registered nurse did not document any other interventions that would determine that the patient still needed bi-lateral restraints. There was no documentation from the physician why the patient needed restraints. There was no documentation from the physician why the patient needed restraints.

On 09/29/10 the Registered Nurse received a phone orders on 09/29/10 at 0000. The order did not contain the name of the physician who gave the order. There was no documentation from the physician why the patient needed restraints.

The "Orders for Medical/Surgical Restraints" continued to be written per nursing for the remainder of the patient's hospitalization. There was no documentation demonstrating that the physician assessed the patient or that nursing staff tried other interventions for the patient. The order for the restraints lacked certain completed components which included the name of the physician giving the order, what limb was to be retrained, physician signatures, nursing assessments as to why the patient needed to continue on the restraints, and the physician's assessment.

On 02/16/11 at approximately 1630 the Chief Nursing Officer confirmed that there was no other place that the information could be found that nursing staff used that least restrictive form of restraint and whether or not the patient received a physician's assessment or the Chief Nursing Officer also confirmed that the physicians order was incomplete.

Based on interview and record review, the facility failed to obtain an order for restraints for 3 of 3 patients restrained (patient's #41, #43, and #44). Findings include:

The policy titled "Restraints" was reviewed on 02/15/11. It states " Assessments-an assessment will be performed by a qualified nurse anytime a situation arises of at the time of admission. Medical/Surgical restraints orders need to include date, time, reason for the restraints, and the duration."

On 02/16/11 at approximately 1330 during record review of patient #41's record, it was revealed that the patient was admitted on 01/20/11. Documentation supports that the restraints were initiated on 01/24/11 at 1700. Review of the document titled "Orders for Medical/Surgical Restraints" dated 01/24/11 revealed that both Right and Left upper limb restraints were started at 1700. There was no documentation to show who wrote the order, or the time and date the order was received. The nurse only completed the "order noted " portion.

01/25/11 documentation shows that only the Left restraint remained on the patient. Review of the document titled "Orders for Medical/Surgical Restraints" dated 01/25/11 contained the signature of the PA-C (Physicians assistant). It did not contain the name of the physician, the date or time the order was taken, or the name of the nurse taking or noting the order nor the signature of the physician ordering the restraint.

01/26/11 documentation shows that only the Left restraint remained on the patient. Review of the document titled " Orders for Medical/Surgical Restraints " dated 01/26/11 contained the signature of the PA-C (Physicians assistant). It did not contain the name of the physician, the date or time the order was taken, or the name of the nurse taking or noting the order nor the signature of the physician ordering the restraint.

01/27/11 documentation shows that both the Right and Left limbs were restrained. Review of the document titled "Orders for Medical/Surgical Restraints" dated 01/27/11 contained the signature of the PA-C (Physicians assistant). It did not contain the name of the physician, the date or time the order was taken, or the name of the nurse taking or noting the order nor the signature of the physician ordering the restraint.

01/28/11 documentation shows that only the Left restraint remained on the patient. Review of the document titled " Orders for Medical/Surgical Restraints" dated 01/28/11 contained the signature of the PA-C (Physicians assistant). It did not contain the name of the physician, the date or time the order was taken, or the name of the nurse taking or noting the order nor the signature of the physician ordering the restraint.

01/29/11 documentation show that only the Left restraint remained on the patient. Review of the document titled " Orders for Medical/Surgical Restraints " dated 01/29/11 contained the signature of the PA-C (Physicians assistant). It did not contain the name of the physician, the date or time the order was taken, or the name of the nurse taking or noting the order nor the signature of the physician ordering the restraint.

On 01/30/11 there was no documented order for the Left limb restraint for 01/30/11. Nursing documentation supported that only the Left restraint remained on the patient.

On 02/16/11 at approximately 1445 during record review of patient #44 ' s record revealed that the patient was admitted on 09/24/10. Documentation supports that the restraints were on when the patient came by ambulance. Review of the document titled " Orders for Medical/Surgical Restraints " revealed that both Right and Left upper limb restraints were started at 1330 per Registered Nurse initiation of the order. There was no documentation why upon admission that the patient still needs the restraints. The Registered nurse did not document any other interventions that would determine that the patient still needed bi-lateral restraints. The physician signed the order on 09/25/10. There was no documentation from the physician why the patient needed restraints.

On 09/25/10 the Registered Nurse received a phone order on 09/25/10 at 0000. The order did not contain the name of the physician who gave the order. The Registered nurse did not document any other interventions that would determine that the patient still needed bi-lateral restraints. There was no documentation from the physician why the patient needed restraints.

On 09/26/10 the Registered Nurse received a phone order on 09/26/10 at 0000. The order did not contain the name of the physician who gave the order. The Registered nurse did not document any other interventions that would determine that the patient still needed bi-lateral restraints. There was no documentation from the physician why the patient needed restraints.

On 09/27/10 the Registered Nurse received a phone order on 09/27/10 at 0000. The order did not contain the name of the physician who gave the order. The Registered nurse did not document any other interventions that would determine that the patient still needed bi-lateral restraints. There was no documentation from the physician why the patient needed restraints.

On 09/28/10 the Registered Nurse received a phone order on 09/28/10 at 0000. The order did not contain the name of the physician who gave the order. The Registered nurse did not document any other interventions that would determine that the patient still needed bi-lateral restraints. There was no documentation from the physician why the patient needed restraints. There was no documentation from the physician why the patient needed restraints.

On 09/29/10 the Registered Nurse received a phone orders on 09/29/10 at 0000. The order did not contain the name of the physician who gave the order. There was no documentation from the physician why the patient needed restraints.

On 02/16/11 at approximately 1630 the Chief Nursing Officer confirmed that there was no other documentation showing that nursing staff used the least restrictive form of restraint. The Chief Nursing Officer also confirmed that the physicians order was incomplete.



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Record review of Patient #43's medical record on 02/14/11 at approximately 1230 revealed that patient #43 was admitted into the facility on 12/16/10 and was ordered soft upper limb bilateral restraints that same day. Review of the Orders for Medical/Surgical Restraints revealed the following:

Telephone orders for the use of soft limb upper restraints were written on 12/16/10, 12/17/10, 12/20/10, 12/21/10, 12/22/10, and 12/23/10. The restraints were initially started 12/16/10 at 1530 with the end time at 0000. The subsequent orders had a restraint start time at 0000 with an ending time at 2359. The telephone orders were written by a nurse but they did not indicate the name of the doctor for whom the order was being written. A physician signed and dated the orders written on 12/16/10 and 12/17/10, but there was only a physician signature on the other orders. It was unclear when the orders were signed and who the doctor was that signed the orders.

Additionally, restraint orders were initiated on 12/27/10, 12/28/10, 12/29/10, 01/02/11 and 01/03/11 with the start time at 0000 and the restraint ending time being 2400 or 2359. The orders written on these dates did not indicate whether or not they were telephone or verbal orders or who wrote the orders, as there was not a nurses name or signature on the orders. Additionally, the signature of the physician was not dated or timed.


Interview with the Chief Nursing Officer on 02/16/11 at 0930 verified that the orders were incomplete.

Based on record review and interview the facility failed to discontinue restraints at the earliest possible time for 1 of 1 patients reviewed (patient#44) Findings include:

On 02/16/11 at approximately 1600 during record review of patient #44's record, it was revealed that the patient was admitted on 09/24/10. Documentation supports that the restraints were on when the patient came by ambulance.

Review of the document titled "Orders for Medical/Surgical Restraints" revealed that both Right and Left upper limb restraints were started at 1330 per Registered Nurse initiation of the order. There was no documentation upon admission to demonstrate that the patient still needs the restraints. The Registered nurse did not document any other interventions that would determine that the patient still needed bi-lateral restraints. The physician signed the order on 09/25/10. There was no documentation from the physician why the patient needed restraints.

The patient remained in the restraints for the rest of the hospitalization. The Registered nurse did not document any other interventions that would determine that the restraints could be discontinued at the earliest possible time. There was no documentation from the physician why the patient needed restraints.

On 02/16/11 at approximately 1630 the Chief Nursing Officer confirmed that there was no documentation showing that nursing staff used that least restrictive form of restraint and whether or not the patient received a physician's assessment or the Chief Nursing Officer also confirmed that the physicians order was incomplete.

Based on interview and record review the facility failed to ensure that 3 of 3 restrained patients (#41, 43, & 44) were monitored while in restraints according to the facility policy. Findings include:

On 02/15/11 at 1400 review of the facility policy on "Restraints" revised 09/10 revealed, "Visualization, monitoring and documentation of the patient in restraints will occur at a minimum every 60 minutes for medical/surgical restraint use. . .Prior to writing an order for restraints, the practitioner must complete a progress note documenting the face to face assessment. The progress note should reflect: Behavior patient is exhibiting, less restrictive measures that have been attempted, and need for continued use."

Record review on 02/15/11 at 1000 revealed that patient #43 was admitted into the facility on 12/16/10 and was ordered soft limb restraints on bilateral upper extremities on the day of admission. Review of the Medical/Surgical "Non-behavioral restraint flow sheets" revealed that there was no restraint monitoring for patient #43 on the following days:

On 12/21/10 from 0300 to 0600, and 1600 to 1800,
On 12/27/10 from 2400 through 0600, and
On 12/31/10 from 0800 through 1800.



Further review of the medical record revealed physician progress notes from 12/16/10 through 01/15/11 (the duration that the patient was ordered medical restraints) but the notes did not indicate if the physician assessed the patient for the continued need for restraints every 24 hours.

Interview with the Chief Nursing Officer on 02/16/11 at 0930 verified that patient #43 should have been monitored at least hourly while in restraints and that the physician should assess the patient before writing orders for restraints.

Based on record review and interview the facility failed to ensure that the Quality Assurance/Performance Improvement Program activities are properly completed. Findings include:

On 2/15/2011 at approximately 1100 review of the Quality Steering Committee (QSC) meeting minutes reveals that the group met three times per year in both 2009 (1/10/09, 5/19/09 and 9/24/09) and 2010 (1/28/10, 5/12/10 and 9/14/10). According the the document titled "Performance Improvement and Utilization Management Plan" the Carelink Quality Steering Committee "provides a quarterly report to the Board highlighting high-risk quality indicators, trends, performance improvement progress towards, goals and compliance related data derived from written summary reports from the clinical services and the individual functional leaders."

On 2/15/2011 at approximately 1100 review of the Quality Steering Committee (QSC) meeting minutes reveals that the Performance Improvement and Utilization Management Plan is evaluated and approved annually. The approval date on the document titled "Performance Improvement and Utilization Management" plan is "reviewed and revised December 21, 2009".

Interview with staff A, E and D, confirmed that the QSC only met three times in 2009 and 2010 due to conflicting schedules and that the 2011 QAPI plan has technically not been approved because the QSC has not met since 9/14/10.

Based on observation and interview the facility failed to ensure pharmaceuticals are stored appropriately and are prepared and administered according to accepted professional principles. Findings include:

On 2/14/2011, 2/15/2011 and 2/16/2011 the medication storage lock on the respiratory therapy cart for the second floor was broken. Interview with staff G on 2/14/11 at approximately 1045 revealed that medication for patients were currently in her pocket. On 2/16/11 at approximately 1100 interview with the respiratory therapist for the second floor confirms that the medications used for respiratory therapy are lockup on the first floor respiratory therapy cart. Interview with staff I regarding how the respiratory medications were dispensed to the second floor confirmed that they were given the the therapist assigned to the floor, he was unaware of where they were being kept.

On 2/15/11 at approximately 1660 during a tour of the first floor nursing unit, an intravenous bag normal saline with added medication, heparin 100 units/ML was found laying in a medication cart in an unmarked drawer with a date of 2/14/11. The expiration date for the IV bag is 2/16/11. Interview of the nurse using the cart reveals that this bag is used among patients needing IV flushes. One syringe (without a needle) is used to withdraw the medication for each patient.
The IV bag is good for 72 hours. Interview with staff I on 2/15/11 at approximately 1000 confirms that the pharmacy reconstitutes a normal saline bag with the appropriate concentration of heparin and the bag is good for 72 hours. When asked for the rationale, Staff I indicated that Sparrow, and U of M are using this practice. Additionally he stated that the manufacturer has provided studies that the use of the one-way valve prevents contamination of the IV solution when used with adequate disinfection procedures. Staff I provided literature supporting the decision to use the IV bag in this manner. Interview with Staff K on 2/16/11 at 0900 reveals that she was aware of the policy however had thought that the IV bag was only to be used for a single patient with the IV bag containing the patient's name.

Review of policy #MM.2.20 titled "Stability for Multi-Dose Vials and Solutions" states...."once started, all parenteral solutions must be infused or discarded within 24 hours. Exceptions are PCA solutions and Intravenous flush solutions with a 1-way valves, which must be discarded within 72 hours". The policy failed to stipulate that each IV flush bag is individually dispensed.

Based on record review and interview the facility failed to ensure quality pharmaceutical services. Findings include:

On 2/15/11 at approximately 1020 during pharmacy tour, review of a physician order and the pharmacy processing of the order for patient #45 reveals that during order entry into the system, the afternoon pharmacist incorrectly noted an order that read "Morphine Sulphate 2 mg IV every 4 hours" as "Morphine Sulphate 2 mg IV every 2 hours". Review of the patients medication administration record confirms that the order was transcribed incorrectly, which was checked and approved by the nurse with the incorrect frequency.

Interview with staff I regarding the checks and balances confirms that the pharmacist who enters the order also checks the same order for accuracy. There are no audits for order entry accuracy being conducted.

Based on record review and interview the facility failed to document nutritional supplements that were ordered by the Registered Dietician for 2 of 2 patients (Patient #3 and #41) Findings include:

On 02/15/11 at approximately 1100 during an interview with the Registered Dietician she stated "Staff should chart it on the med sheet. If it's on the flow sheet that's an added bonus."
On 02/15/11 at approximately 1130 the Chief Nursing Officer confirmed that there was no other place that the information could be found and whether or not the patients received the nutritional supplements or the amount that the patient consumed.

Based on record review and interview the facility failed to provide the documentation that their diet manual was authorized for patient use by the Registered Dietician and the hospital Medical Staff. Findings include:

During an interview with the Registered Dietician on 02/15/11 at approximately 1100 it was determined the facility's therapeutic diet manual is online and is easily accessible to all staff members. There was no hard copy in the facility.

On 02/16/11 at 1620 the Chief Nursing Officer confirmed that there was not a hard copy of the diet manual and had not been approved by the Registered Dietician or the Medical Staff.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated February 15, 2011 for Life Safety Code.

Based on observation, record review and interview, facility failed to promptly remove accumulated red-bagged trash. Findings include:

On 2/14/11 at approximately 1100 during observational tour of the soiled utility on the second floor, two covered red containers were overflowing with red-bagged trash and there were three full needle boxes stored on the floor. There was a detectable and strong odor in this room.

Facility's policy titled "Contaminated Waste Disposal", fails to stipulate frequency of contaminated waste pickup from each of the units. Interview with staff #L reveals that he is unaware of the scheduled pick up for trash, however agreed that these trash bins were in need of emptying.

Based on observation, record review and interview the facility failed to ensure equipment is cleaned between use for patients. Findings include:

On 2/14/11 during facility tour of the second floor, observed Staff #H performing an accucheck ( blood glucose monitoring procedure) on a patient bringing the meter (Carelink #1 1853) into the patient care room. After completion of the procedure, she proceeded to wipe down the accucheck machine with an alcohol wipe, with the contaminated gloves which were also used to perform the accucheck procedure. She went on to the next room, which was a contact isolation room, and performed another accucheck procedure on the patient, again, bringing the machine into the room and setting the machine on the arm of the chair. Upon completion of the procedure, she again wiped down the machine with an alcohol wipe, with her contaminated gloves. Upon returning the machine to the base at the nurses station, the meter was found to have much black-stained white tape wrapped around the base of the meter.

The facility's policy titled "Blood Glucose Using the Roche Inform Blood Glucose Monitoring System" fails to stipulate in the "Patient Testing Procedure" how and when to clean the machine between patients. Additionally, equipment disinfection cannot be achieved when residual tape is remaining on the unit. After interviewing staff #H regarding the cleaning of the machine, she indicated that the machine should have been brought into the isolation room in an enclosed plastic bag. Staff H was unaware that cleaning the machine with an alcohol wipe using the same contaminated gloves with which she performed the procedure was unacceptable practice.

On 2/14/11 at approximately 1600 during facility tour of the first floor nursing unit the following were observed:
1). a free standing air conditioner unit had accumulated dust on the air filters located on the side of the unit. Staff #F was unaware of the filter cleaning frequency, however admitted they were dusty.
2). In the common use tub room in a three drawer storage cabinet, two hot-iron hair curling units were found with residual hair remaining in them. Interview with staff #F reveals that these units are not cleaned between uses
3). In the nurses station a storage box containing a hair clipping unit with scissors, attachments and combs were found with residual hair in the clippers and in the bottom of the storage box. Interview with staff #F revealed that one of the nurses is a licensed cosmetologist and will occasionally cut the patients hair. Staff #F was unaware of any clipper/attachments/combs cleaning procedures used between patient uses.

The facility failed to provide adequate temperature the the ICU area. Findings include:

During the facility tour with the COO, Director, and maintenance manager on February 15, 2011 at approximately 10:00 AM, it was noticed that their was a portable air conditioning unit in the ICU unit. The patients in the 5 ICU rooms within this unit also had fans in each of their rooms to help keep them cool. The maintenance manager stated that the fans and portable air conditioning unit was needed because Air Handling Unit #7 that served the ICU unit did not have the capacity to keep the unit cool enough. This unit is on the master plan to be replaced however there it no time table to when this work will be done.

Based on observation, record review and interview, the Infection Control Officer failed to ensure a sanitary environment. Findings include:

On 2/14/11 during observational tour the following were observed:

1) In an empty, patient-ready room (#218), the vent immediately next to the bed had at least 1/4 inch of dust covering the internal components of ventilation system. In the same room on the inside of both upper siderails of the bed, the siderails had residual brown stained material that could be whetted and removed using a paper towel. An intravenous (IV) pole that was patient ready, had residual tape remaining on the pole. Staff #L confirmed that this was a patient ready room. When asked regarding quality environmental checks/rounds, he was unaware of the presence or frequency of those environmental rounds. An environmental rounds sheet for this room was provided with a completion date of 1/26/11 revealing the need for toilet seat repair (looseness, damage, discoloration) and the toilet paper holder being loose. The quality check repair was completed by L Stage on 1/27/11.
2). On the second floor nursing unit in the clean utility room, a laboratory phlebotomy supply tray was found to have accumulated dust, and debris on the bottom of the tray in addition to a reddish sticky substance coating the bottom of the tray. Additionally, clean supplies were found stored around the handwashing sink, at risk for splash contamination when the the sink is used. Staff #L confirmed these findings, and was unaware of any cleaning schedule for the phlebotomy tray.
3). On the second floor soiled utility room: storage cabinet faces and internal shelving was found to be dusty and stained with dark colored materials. A used utility glove and used disposable exam glove was found discarded among the assorted bed parts in one of the storage cabinet. The soiled linen hamper; foot opening mechanism was found to be non-operational, and the lid was soiled with blackish material on the top and around the sides. Staff #L confirmed the condition of the soiled utility room, and would put in for a work order to get the linen cart fixed.
4.) On the second floor linen storage area, the clean fitted sheets were found to be stored in an uncovered bin.
5). On the second floor pantry area the following were found:
a. storage around the handwashing sink of patient care supplies
b. under sink openings in wall board
c. Soiled storage cabinets and drawers used to store patient supplies
d. Ice machine chute was soiled with orange colored materials
e. Used pop can storage was overflowing onto the floor
f. the floor was stained and dusty in the corners.
g. both refrigerators has accumulated stains in the bottom and the drawers were stained with brownish material
6. On the second floor nurses station, next to the Pixis system, dust was accumulated between the Pixis system and the storage cabinet.
Staff # L confirmed the conditions found on the second floor nursing unit. He was unable to cite cleaning frequency of these areas.
7). On the first floor in the pantry the refrigerators were dirty and the crisper drawer had accumulated brownish material. Additionally the used pop can bin was overflowing onto the floor. Staff F confirmed the condition of this room and was unaware of the cleaning frequency of the pantry refrigerators.

On 2/16/11 at appproximately 0900 interview with staff K confirms that another person not the infection control officer, is responsible for monitoring the quality of the environment.

On 2/14/11 Staff G was found in isolation room #208 providing a breathing treatment using the following personal protective equipment (PPE): a mask (pulled down from her nose) and disposable gloves. The sign on the door stipulates the need to use a gown, a mask and disposable gloves. Policy titled "Isolation (Transmission Based Precautions)" fails to stipulate PPE requirements for contact isolation precautions. Interview with staff E confirms that the staff should have worn a gown and pulled up the facemask to protect her nose from spray contamination.


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During the initial tour of the facility on 2/14/11 at approximately 1100 it was observed that in room 200 the patient had orders to be placed on droplet precautions. The sign on the entrance of the patient's room stated the type of precaution, droplet, and the necessary personal protection equipment (PPE) to be used, gloves, gown and mask. A visitor of the patient's was observed in the patients room placing socks on the patient and had none of the PPE needed to safely engage with the patient.

During an interview with staff N on 2/14/11 at approximately 1105 when asked what PPE should be worn by visitors, she stated, "the same as staff, gloves, mask and gown".

During an interview with staff O on 2/14/11 at approximately 1130 when asked about the type of education visitors receive in regards to isolation precautions, she stated, "they are educated on the requirements of PPE when the patient is admitted, but it's hard to enforce that visitors wear the PPE."

Based on Donation Log Sheet/Routine Notification Sheet review, interview and policy and procedure review, the facility failed to ensure timely notification and completed documentation for its organ procurement responsibilities. Findings include:

During review of the facilities policy and procedure titled, "Organ and Tissue Donation Procurement", on 2/15/11 at approximately 1430 it states, "Timely referral: The Donor Hospital agrees to make a "timely notification" referral by telephone to GIFT OF LIFE 1-800-482-4881 within 30 minutes when: c. an individual has died from any circumstance".

During review of 34 Donation Log Sheet/Routine Notification Sheets, (the form the facility uses for the notification and documentation of information given to Gift of Life), on 2/15/11 at approximately 1430, for the time period of 8/10/10 thru 2/8/11 it was found that 20 out of 34 sheets were not completely and accurately filled out, making exact notification time to Gift of Life impossible to determine.

During an interview with staff A and E on 2/15/11 at approximately 1500, these findings were confirmed.

Based on interview the facility failed to verify the effectiveness of its organ procurement program and policies by not including it as a part of the facilities quality improvement program. Findings include:

During an interview on 2/15/11 at approximately 1500 with staff A and E, when asked how organ procurement was integrated into the facilities quality improvement program, it was stated by both staff members that there was no quality improvement indicators nor was organ procurement integrated into the quality improvement program.