UPMC Mckeesport Hospital

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45574 Based on a review of facility documents, medical records (MR) and employee interview (EMP), it was determined that the facility failed to ensure the documentation of ongoing clinical assessment, every two hours for the patient in restraints in three of five medical records (MR2, MR3, and MR4). Findings include: On January 9, 2025, a review of policy HS-NA0416, “Restraint and Seclusion” (Last Reviewed: July 30, 2024) was completed and revealed the following: Section “VIII. Use of Restraint for Non Violent/Non Self- Destructive Behavior D. Ongoing Patient Assessment and Care Interventions: 4. The continued need for the use of restraint for Non Violent/ Non Self- Destructive behavior will be reassessed and documented in the medical record at the following frequencies or more often as the patient condition requires. (a)_Non Violent/ Non Self- Destructive behavior - every 2 hours 5. The documented assessment may include but will not be limited to: a. Release of restraint; b. Color, sensation and movement of the involved extremity(ies); c. Skin integrity/signs of injury; d. Readiness for restraint discontinuation based on observed behaviors: e. Alternatives provided to the patient.” On January 9, 2025, a review of MR2 revealed the patient was placed in soft wrist restraints on January 6, 2025, at 3:05 PM. There is no evidence of the required two hour re-assessment on January 9, 2025, at 10:00 AM and 12:00PM. There is no evidence/documentation that the restraint was discontinued in the medical record. On January 9, 2025, a review MR3 revealed that the patient was placed in soft wrist restraints on October 18, 2024, at 5:01 PM. There is no evidence of the required two hour re-assessment on October 18, 2024 at 10:00 PM; on October 19, 2024 at 6:00 AM, 4:00 PM, and 6:00 PM; on October 20, 2024 at 6:00 AM; and on October 21, 2024 at 12:00 PM and 2:00 PM. On January 9, 2025, a review MR4 revealed that the patient was placed in soft wrist restraints on November 23, 2024, at 6:48 PM. There is no evidence of the required two hour re-assessment on November 24, 2024, at 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, and 6:00PM. There is no evidence/documentation that the restraint was discontinued in the medical record by the nursing staff. On January 9, 2025, EMP1 confirmed the above findings between 1:15 PM and 1:29 PM.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46390 Based on a review of facility documents, medical records (MR), observation, and staff interview(EMP), it was determined that the facility failed to supervise the patient’s care to ensure the patient’s cardiac status was being monitored at all times for one of ten medical records reviewed (MR1). Findings include: On January 9, 2025, a review of the policy, “Telemetry Monitoring” (HS-HD-CP-22; Last Reviewed: September 4, 2024, was completed and revealed the following: “I. Policy: It is the policy of UPMC to provide standardized, consistent care of patients undergoing continuous cardiac monitoring ...IV: Procedure: 1. Monitor Orders and Association: a. Monitor Orders and Evaluation: 1. A physician and/or the advanced practice provider will assess the need and provide the order for the cardiac rhythm monitoring ... b. Monitor Associations 1. Confirm cardiac monitor order 2. Upon admission to the designated area, the patient who is ordered cardiac rhythm monitoring will be connected to the bedside monitor and/or telemetry, as is appropriate to the unit monitoring system 3. Associate the telemetry product with the patient by confirming the telemetry equipment number and verify correct patient identifiers 4. Confirm monitor is in view in all necessary locations. Section 4. Cardiac Monitor Nursing Documentation: a. Electronic Health Record Documentation: 1. The patient’s cardiac rhythm waveform will be documented at transition or handover of care personnel and with any condition change that requires provider notification. b. Printed Cardiac Waveform Documentation: 1. Cardiac rhythm will be captured upon admission to the designated area and with any condition change that requires provider notification.” On January 9, 2025, a review of Policy MCK-PE1020, “Assessment/Reassessment of Patients” (Last Reviewed: May 2024) was completed and revealed the following ...”Then Nurse should complete a reassessment as frequently as indicated by patient’s condition, complexity of patient’s needs, and the need to provide continuity of care. ...While the collection of reassessment data may be delegated to an authorized staff member, provided it is within the staff members’ scope of practice, the responsibility and accountability for collecting and analyzing the reassessment data and the modification sofa patient specific plan of care remains with the professional nurse”... On January 9, 2025, a review of MR1 revealed that the patient was admitted on December 11, 2024, and was a 76-year-old, with a history of Asthma, Benign Prostatic Hypertrophy, COPD, GERD, Rectal Adenocarcinoma, Periperal Vascular Disease, Aortic Stenosis and Hypertension. MR1 was admitted after presenting to the Emergency Department with cough, fatigue, and chest discomfort that been going on for eight days prior to coming to the hospital. MR1 described the feeling as an anterior chest sensation that occasionally radiated to his back and coughing up clear colored sputum but denied fever or chills. MR1 was admitted to the hospital with a diagnosis of Influenza A, and Elevated Troponin of 7000, and Chest Heaviness. The electrocardiogram revealed an ST elevation, and the initial impression was Pericarditis. On December 11, 2024, the admitting physician ordered continuous cardiac monitoring. The initial reading on the cardiac monitor was normal sinus rhythm (NSR). Cardiology was consulted to see MR1 while in the hospital. On December 12, 2024, at 5:33 AM, a Condition A was called for MR1. Upon arrival of the Code Team, CPR was initiated. A review of the monitor revealed that the patient came off the monitor at 3:30 AM. The Code Team continued cardiopulmonary management for a total of twenty-two minutes and performed eleven cycles of CPR. Despite these interventions, the patient remained in asystole and had no pulse at each rhythm and pulse check. After twenty-two minutes of resuscitation the patient was pronounced dead at 5:59 AM. MR1’s spouse was notified, and the preliminary cause of death was Viral Myopericarditis and Influenza A. Further review of MR1 revealed no documentation to support that an RN supervised nursing care or reassessed the patient from 3:00AM until 5:33 AM when MR1 was found off the cardiac monitor and asystole. On January 9, 2024, the above findings were confirmed at 11:15 AM by EMP1.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46390 Based on a review of facility documentation, medical record (MR), and employee interview (EMP), it was determined the facility failed to ensure staff adhered to the policies and procedures of the hospital for the cardiac monitoring in one of ten medical records (MR1). Findings include: On January 9, 2025, a review of the policy, “Telemetry Monitoring” (HS-HD-CP-22; Last Reviewed: September 4, 2024, was completed and revealed the following: “I. Policy: It is the policy of UPMC to provide standardized, consistent care of patients undergoing continuous cardiac monitoring ...IV: Procedure: 1. Monitor Orders and Association: a. Monitor Orders and Evaluation: 1. A physician and/or the advanced practice provider will assess the need and provide the order for the cardiac rhythm monitoring ... b. Monitor Associations 1. Confirm cardiac monitor order 2. Upon admission to the designated area, the patient who is ordered cardiac rhythm monitoring will be connected to the bedside monitor and/or telemetry, as is appropriate to the unit monitoring system 3. Associate the telemetry product with the patient by confirming the telemetry equipment number and verify correct patient identifiers 4. Confirm monitor is in view in all necessary locations. Section 4. Cardiac Monitor Nursing Documentation: a. Electronic Health Record Documentation: 1. The patient’s cardiac rhythm waveform will be documented at transition or handover of care personnel and with any condition change that requires provider notification. b. Printed Cardiac Waveform Documentation: 1. Cardiac rhythm will be captured upon admission to the designated area and with any condition change that requires provider notification.” On January 9, 2025, a review of Policy MCK-PE1020, “Assessment/Reassessment of Patients” (Last Reviewed: May 2024) was completed and revealed the following ...”Then Nurse should complete a reassessment as frequently as indicated by patient’s condition, complexity of patient’s needs, and the need to provide continuity of care. ...While the collection of reassessment data may be delegated to an authorized staff member, provided it is within the staff members’ scope of practice, the responsibility and accountability for collecting and analyzing the reassessment data and the modification sofa patient specific plan of care remains with the professional nurse”... On January 9, 2025, a review of MR1 revealed that the patient was admitted on December 11, 2024, and was a 76-year-old, with a history of Asthma, Benign Prostatic Hypertrophy, COPD, GERD, Rectal Adenocarcinoma, Periperal Vascular Disease, Aortic Stenosis and Hypertension. MR1 was admitted after presenting to the Emergency Department with cough, fatigue, and chest discomfort that been going on for eight days prior to coming to the hospital. MR1 described the feeling as an anterior chest sensation that occasionally radiated to his back and coughing up clear colored sputum but denied fever or chills. MR1 was admitted to the hospital with a diagnosis of Influenza A, and Elevated Troponin of 7000, and Chest Heaviness. The electrocardiogram revealed an ST elevation, and the initial impression was Pericarditis. On December 11, 2024, the admitting physician ordered continuous cardiac monitoring. The initial reading on the cardiac monitor was normal sinus rhythm (NSR). Cardiology was consulted to see MR1 while in the hospital. On December 12, 2024, at 5:33 AM, a Condition A was called for MR1. Upon arrival of the Code Team, CPR was initiated. A review of the monitor revealed that the patient came off the monitor at 3:30 AM. The Code Team continued cardiopulmonary management for a total of twenty-two minutes and performed eleven cycles of CPR. Despite these interventions, the patient remained in asystole and had no pulse at each rhythm and pulse check. After twenty-two minutes of resuscitation the patient was pronounced dead at 5:59 AM. MR1’s spouse was notified, and the preliminary cause of death was Viral Myopericarditis and Influenza A. Further review of MR1 revealed no documentation to support that an RN supervised nursing care or reassessed the patient from 3:00AM until 5:33 AM when MR1 was found off the cardiac monitor and asystole. On January 9, 2024, the above findings were confirmed at 11:15 AM by EMP1.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 46390 Based on a review of facility documents, medical records (MR) and employee interviews (EMP), it was determined that the facility failed to maintain a safe environment for psychiatric patients who eloped from the hospital for one of 20 medical records reviewed (MR1). Finding include: On December 11, 2024, a review of facility policy “Care Attendant Utilization and Observation of Patients”, last reviewed February 2024, revealed the following: “Policy: ...UPMC will utilize Care Attendants when necessary to provide observation for patients on inpatient nursing units and in emergency department, in accordance with established standards. ... This policy outlines the role and responsibilities of the Safety Care Attendant and the Psychiatric Care Attendant. ... Safety Care Attendant: Provides patient care, support and constant observation in accordance with established policies and procedures under the direction of the RN/LPN, physician, or provider with prescriptive authority. Routinely performs ... constant observations, ... transfer and ambulation assistance, and patient comfort measures. Psychiatric Care Attendant: Provides constant observation or special constant observation to assigned suicidal or behavioral health patients under the direction of provider ... As a result, the Psychiatric Care Attendant will have limited direct care responsibilities so that the patient remains in direct eyesight or, as ordered, within arm’s reach at all times. As a result, the Psychiatric Care Attendant may not complete other care or [activities of daily living] ADLs for the patient that would require the Psychiatric Care Attendant to leave the room (such as going to the patient’s bathroom) or turn their back to the patient. ... Constant Observation (CO): Whereby the staff continuously observes and may interact individually with the patient while keeping the patient in sight at all times. Additionally, the patient’s hands must be visible at all times to the CO staff or Care Attendant. ... Patients on CO status may have issues that jeopardize their safety or the safety of others. ... that require staff or a Care Attendant to be observing them at all times to ensure their safety. ... Psychiatric Care Attendant: The request of a psychiatric care attendant for suicidal or behavioral health patients requires the order of a physician. ... Discontinuation of a psychiatric care attendant can only be completed with a physicians order.” On December 11, 2024, a review of facility policy “Observation of Behavioral Health Patients”, last reviewed July 2024, revealed the following: “It is the goal of UPMC McKeesport to ensure the safety of behavioral health patients seeking care and evaluation in the Emergency Department by protecting them from their self and others through close observation. ... The observer will document their observations on the Constant Observation Flowsheet, which is a print on demand document. 4. If the behavior of the observed patient indicates the possibility of them incurring imminent harm or eloping from the emergency department, the nurse or provider shall be immediately notified and UPMC Police/Security summoned as deemed appropriate. ... 6. The elopement of any behavioral health patient requires the immediate notification of the ED Charge Nurse, ED Leader or ED leader on-call, and provider to discuss the appropriate response.” On December 11, 2024, a review of facility policy “Restraint and Seclusion” last reviewed July 2024, was completed and revealed: “... Documentation. A. Appropriate documentation is to be made for each patient placed in restraint or seclusion as part of a modified plan of care. B. For each episode of restraint or seclusion use, all assessments and all interventions are to be documented.” Review of MR1 on December 11, 2024, revealed that the patient was a 39-year-old female with a history of psychiatric disorders, who arrived in the facility’s Emergency Department (ED) for a psychiatric evaluation, on November 8, 2024, accompanied by police as an involuntary commitment (302) after concerned behavior at home. The patient was found in her apartment burning paper and was attempting to make a campfire. Further review of the medical record revealed that the patient was placed in a patient room due to the Columbia Suicide Severity Rating Scale. MR1 had positive thoughts for suicide and was completely undressed and placed in a green hospital gown. MR1 has a history of suicidal ideation, Bipolar illness, substance abuse, alcohol abuse, borderline personality disorder and abusive behavior to staff while in the hospital. MR1 eloped from the ED on November 9, 2024. On December 11, 2024, a review of MR1 revealed a physician order was placed November 8, 2024, at 9:38 A.M. for a Psychiatric Care Attendant with constant observation. However, the facility was unable to provide documentation that constant observation occurred until November 9, 2024, at 7:00am, which was 21 hours after the order was placed. On December 10, 2024, a review of surveillance video from the Emergency Department dated November 9, 2024, at approximately 8:27 PM, revealed the following: At 8:27 PM, EMP4 [sitter] is seen seated across the hallway from the “quiet room”, with a desk in front of their person. The doorway to the quiet room is ajar. MR1 emerges at approximately 8:28 PM. MR1 has a blanket draped over their head and shoulders, with hands wrapping the blanket to their chest. MR1 exits the room, past EMP4, with blanket in the same position. EMP4 stands and begins to follow MR1 past the nurses’ station, as they progress down the corridor toward the exit. MR1 is seen shifting toward the side of the hallway where the exit is located and pauses in the doorway. EMP4 appears to shift, placing themselves in front of the patient. MR1 runs to the right of the surveillance view and EMP4 reaches to stop them, grasping the blanket. In the next piece of video, MR1 is seen running past an unattended security desk station through two sets of open automatic sensor doors. The above was confirmed by EMP1 on December 11, 2024, at 1:00PM.”