"Her actions were indeed baffling." the report said.
Another report conducted by the state for the federal Centers for Medicare and Medicaid Services and released Monday said poor oversight and communication and insufficient policies were factors in the kidney's disposal.
The botched transplant led to the voluntary, temporary suspension of the hospital's living-donor kidney transplant program and to reviews by health officials and a consulting surgeon hired by the hospital. One nurse was fired and another resigned.
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 have 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.
Levy wrote that he did not interview the nurse who threw away the kidney because she had been placed on leave. He said that the nurse had missed several signs that should indicated that the kidney transplant had not been completed.
He also said it was baffling that others on the transplant team didn't see the nurse dismantle the machine that keeps the organ cool until it is transplanted or see her remove the contents.
The nurse said she didn't realize the kidney was in chilled, protective slush that she removed from the operating room and "flushed down a hopper," according to the review conducted by the state.