| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 05P002 | (X3) Date Survey Completed 03/19/2010 |
| Name of Provider or Supplier Onelegacy | Street Address, City, State 221 S Figueroa St, Suite 500, Los Angeles, CA | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| Z0342 | ADVERSE EVENTS CFR(s): 486.348(c)(2) (2) The OPO must conduct a thorough analysis of any adverse event and must use the analysis to affect changes in the OPO ' s policies and practices to prevent repeat incidents. This STANDARD is not met as evidenced by: Based on record reviews and staff interviews, the OPO failed to conduct a thorough analysis of an adverse event. This failed practice has the potential of repeat incidents and does not allow the opportunity to affect corrective change to policy and practices. This occurrence was found in one of eighteen sampled donor records reviewed. Finding includes: On 3/17/10 at 9:15 a.m., a record review of Donor 2's progress notes dated 1/18/07 at 8:00 a.m., 10:00 a.m., and 10:00 p.m., stated that the surgeon from a local transplant hospital called to inform the OPO that they had received the right kidney instead of the left kidney that was requested. No adverse event documentation of the incident was found in the donor record as per the OPO policies QS07.08v2, QS07.10v2 and QS07.13v2. On 3/18/10 at 2:52 p.m., in an interview with a quality improvement staff, when questioned about the adverse event, she stated that an investigation of the event was in progress and no adverse event documentation was found regarding the kidney mix-up. The investigation had determined that the person who wrote the note about the kidney mix-up was no longer working at the OPO as of a month ago. On 3/18/10 at 3:05 p.m., in an interview with another quality improvement staff, she stated that a review of the OPO records and Donor Net records showed that the correct organs went to the transplant centers that the organs were initially intended to be delivered and that the organs were transplanted. She stated that no documentation was available to explain how the mix-up occurred. The staff added that she would write a summary that would explain the event from available documentation. On 3/18/10 at 4:45 p.m. in an interview with the quality improvement staff, she stated that the courier service confirmed that the right and left kidneys went to the correct transplant centers. She stated that there was a problem with the packaging. She said that the local transplant center transplanted the correct kidney and that another transplant center was supposed to get the left kidney. |