| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 05P002 | (X3) Date Survey Completed 03/21/2014 |
| 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) |
| Z0188 | DONATION AFTER CARDIAC DEATH CFR(s): 486.344(f)(2) [If an OPO recovers organs from donors after cardiac death, the OPO must have protocols that address the following:] Withdrawal of support, including the relationship between the time of consent to donation and the withdrawal of support; This STANDARD is not met as evidenced by: Based on record review and interview, the OPO did not ensure that it's policy and procedure on donation after cardiac death included the provision that no member of the recovery team was to be in the operating room until after death had been pronounced. Finding includes: Review of the OPO's policy and procedure on Donation After Cardiac Death revealed that while the OPO outlined several steps that staff would follow to facilitate donation after cardiac death including donor evaluation, authorization, pre-operating room huddle, withdrawal of life sustaining treatment, pronouncement of death, and organ recovery, the policy and procedure however did not include a provision that recovery personnel or members of the transplant team must not be in the operating room until after death had been declared. During an interview on 3/19/4 , an OPO staff stated that while one staff was allowed in the operating room to document the sequence of events of withdrawal of life sustaining treatment, the OPO however made sure that no one from the recovery or transplant team was inside the operating room until after death was pronounced. |