The nurse said she didn't realize the kidney was put in the sterile, semi-frozen solution because she had been on a break, with a different nurse in her place, when a surgeon made that announcement during the Aug. 10 transplant at the University of Toledo Medical Center, according to a review conducted by the state for the federal Centers for Medicare and Medicaid Services and obtained by The Associated Press through a records request.
Hospital administrative staff members interviewed on Aug. 21 hadn't determined how the nurse took the 13-gallon bag of slush, meant to extend the kidney's viability, past several members of the medical staff without them noticing a problem, the report said.
It said poor oversight and communication and insufficient policies were factors in the kidney's disposal, which prompted the voluntary, temporary suspension of the hospital's living-donor kidney transplant program and led to reviews by health officials and a consulting surgeon hired by the hospital.
The hospital, in northwest Ohio about 135 miles north of Columbus, "failed to provide adequate supervision and communication resulting in a donor's kidney being carried out of the operating room, down a hall, into a dirty utility room, and flushed down a hopper," the report stated.
The hospital has since enacted clearer policies to clarify communication between nurses who fill in for one another and to make sure nothing is removed from an operating room until the patient has been moved from it, the report said.
The surveyors determined the hospital wasn't in compliance with Centers for Medicare and Medicaid Services, or CMS, conditions of participation for transplant and surgical services. CMS will authorize a full review of the conditions of participation for the hospital, and, if it's found out of compliance, it could be terminated from the Medicare program, CMS spokeswoman Elizabeth Surgener said in an email.
The hospital, which says it offers specialty care in areas including cardiology, cancer, surgery and kidney transplantation, also may submit a plan of correction.
A spokesman said he had no comment to provide from the hospital Monday.
The hospital hasn't said what happened to the intended kidney recipient, who was supposed to receive an organ donated by her brother. The intended recipient and her brother were released from the hospital, which didn't identify them and said it couldn't say whether she received a different kidney.
Hospital officials apologized and hired a Texas surgeon to evaluate their transplant procedures but have not released the results of that evaluation.
The medical center suspended two nurses after the incident; one was later fired, and the other resigned, the hospital said. A surgeon was stripped of his title as director of some surgical services, and a surgical services administrator put on paid leave has resumed work.
The hospital also notified 975 patients and potential organ donors and recipients that they might need to make other arrangements for services typically provided through the program under review.