UPMC Pinnacle Hospitals

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 41272 Based on review of facility documents, medical record review (MR), and staff interview (EMP) it was determined the facility failed to provide a medical screening examination to a patient that presented to the Emergency Department for one of twenty-one medical records reviewed (MR21). Findings include: Review of policy “Emergency Medical Treatment and Active Labor Act (EMTALA)” with a date of August 29, 2025, revealed “... II PURPOSE: This policy sets forth the system hospital’s requirements under EMTALA, including guidelines for providing appropriate setting (department) for conducting medical screening for all individuals including every infant born alive. ... IV DEFINITIONS ... 2 Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant women, the health of the women or her unborn child) in serious jeopardy, serious impairment to bodily functions; or serious dysfunction of any bodily organ or part; .... 4. Medical Screening Exam (MSE) is an exam within the capability of the hospital to determine whether an emergency medical condition exists. ... V. PROCEDURE 1. If an individual seeking emergency medical care, the hospital ’ s Dedicated Emergency Department QMP shall offer a Medical Screening Exam ...” Review of MR21 on February 18, 2026, revealed the patient presented to the Emergency Department on January 27, 2026, with complaints of mouth sores. Further review of MR21 revealed the patient was registered and checked in. The patient was displaying inappropriate behaviors and threatening staff and was escorted out by police, prior to having a medical screening completed. Interview on February 18, 2026, with EMP5 at 2:45 PM confirmed the patient did not have a medical screening prior to being escorted out.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 41272 Based on review of medical records (MR), tour and interview with staff (EMP), it was determined that the facility failed to provide a safe physical environment when they failed to prevent a patient (MR1) with access to a lighter, from starting a fire inside the hospital emergency department. The identified non-compliance constituted a determination of Immediate Jeopardy (IJ) at §482.41 Condition of Participation: Physical Environment. A discussion took place with the survey team and the facility’s administrative staff regarding the survey team’s concern related to Physical Environment on January 2, 2026, at 9:00 AM. The Immediate Jeopardy (IJ) was identified, and called at 10:50 AM on January 2, 2026, regarding the lack of signage, lack of education to smokers, smokers’ access to lighting materials and the failure to implement measures to prevent reoccurrence. The facility submitted an acceptable Immediate Jeopardy Removal Plan to include adding no smoking signage, education, securing fire-starting materials once a patient is identified as a smoker, and audits to monitor compliance. On January 5, 2026, at 3:00 PM, the IJ was resolved after the State Survey Agency verified that the hospital implemented immediate corrective actions removing the immediate risk to patients. Cross Reference 482.41(a) Physical Environment Buildings 482.23(b)(6) Supervision”

“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: 41272 Based on review of facility documents, medical record review (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that a smoking assessment, education and smoking cessation was offered to eight of ten medical records reviewed who were identified as a smoker (MR1, MR4, MR5, MR6, MR7, MR8, MR9 and MR10). Findings: On January 5, 2025, review of facility document “Code of Conduct Smoking Prohibited While Receiving Treatment” with a last updated date of August 6, 2025, states “UPMC is committed to delivering quality medical care to the patients we serve. We seek to ensure the protection of each patient’s physical and emotional health and safety. It is our aim to provide quality medical services in an environment that respects each patient’s individuality and dignity. Part of your role as a patient is to cooperate with all hospital staff. You are responsible for following all hospital regulations, expectations, and guidelines. ... We know that it can be stressful to be a patient in the hospital. However, all UPMC hospitals are non-smoking facilities. If you smoke, your doctor can order an alternative to smoking such as patches, gum, medication, or other such treatments to assist you. Please inform your doctor or nurse if you are interested in a product to help you quit smoking or refrain from smoking during your hospital stay. If you leave the hospital to smoke for any reason, your physician may discharge you from the hospital. Additionally, please note that smoking is not permitted anywhere inside the hospital or on hospital property. This policy is in place to ensure the health and safety of all patients, visitors, and staff. Hospitals may have oxygen in the walls making smoking extremely dangerous. Smoking in the hospital may cause a fire and harm to you and others. We appreciate your cooperation in adhering to this policy. ... Staff signature below acknowledges that 1. I have reviewed the statements set forth above in this document with the patient. 2. I have ensured patient has a copy of the UPMC Patient Rights and Responsibilities. 3. I have explained that continued failure to comply with the responsibilities as outlined in the UPMC Patient Rights and Responsibilities may compromised the ability of UPJMC hospital to care for the patient. 4. A copy of this agreement will be placed in the patient’s medical record. Patient Signature below acknowledges that: I understand the UPMC Patient Rights and Responsibilities and agree to abide by the expectations outlined in the Agreement for the remainder of my visit with UPMC.” Signature line then follows. On January 2, 2025, a request was made for a smoking assessment policy. None was provided. Review of MR1 revealed the patient was brought to the emergency department (ED) by an ambulance from the Greyhound bus stop, on December 20, 2025, at 2333, for complaints of abdominal pain. MR1 revealed documentation that the patient smokes cigarettes at a volume of one pack a day. Review of MR1 revealed there was no Code of Conduct Smoking Prohibited While Received Treatment in the medical record. Further review of MR1 revealed there was no smoking assessment completed. MR1 contained no evidence that education was provided, or smoking cessation was offered. In addition, smoking paraphernalia was not removed, and the patient lit a cigarette and blanket on fire while in the ED. Review of MR4 revealed the patient was identified as a smoker on December 29, 2025, and had no smoking assessment, education or smoking cessation offered in the medical record. Review of MR5 revealed the patient was identified as a smoker on October 20, 2025, and had no smoking assessment, education or smoking cessation offered in the medical record. Review of MR6 revealed the patient was identified as a smoker on October 3, 2025, and had no smoking assessment, education or smoking cessation offered in the medical record. Review of MR7 revealed the patient was identified as a smoker on September 28, 2025, and had no smoking assessment, education or smoking cessation offered in the medical record. Review of MR8 revealed the patient was identified as a smoker on October 18, 2025, and had no smoking assessment, education or smoking cessation offered in the medical record. Review of MR9 revealed the patient was identified as a smoker on November 2, 2025, and had no smoking assessment, education or smoking cessation offered in the medical record. Review of MR10 revealed the patient was identified as a smoker on October 26, 2025, and had no smoking assessment, education or smoking cessation offered in the medical record. Interview with EMP1 on January 2, 2026, at 09:25 AM, EMP1 was asked if any interventions were put in place following the fire and they stated no. EMP1 was asked if there was an assessment for smoking in the E-MAR and they stated no, it does not populate for nursing to address if a smoker is marked. Interview with EMP2 on January 2, 2026, at approximately 2:30 PM confirmed cessation and smoking education was not completed in the charts reviewed. EMP2 stated “it is not available to click on when the nurse is assessing the patient and the nurse would have to search for it which wastes time”.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 41272 Based on review of facility documents, medical record review (MR), facility tour and interview with staff (EMP), it was determined the hospital failed to ensure the physical environment of the hospital was safe for patient care since they failed to provide adequate no smoking signage and failed to secure smoking materials, to prevent a patient (MR1) with access to a lighter, from starting a fire inside the hospital emergency department. . Findings On January 2, 2025, review of facility policy titled “Patient Belongings and Valuables” with a written date of May 24, 2024, stated under I. Purpose: “The purpose of this procedure is to provide guidance for staff to follow to support the safekeeping of patient’s property and valuables. ... III. Belongings Definitions: Articles of Daily Living: items or devices needed for performing activities of daily living ... Clothing/Non-clothing: garments, toilet articles, books, etc. ... Valuables: cash, important documents, etc. ... IV. General Guidelines 1. On arrival to Emergency Department, Pre-Procedural Area, or Nursing Unit, the patient belongings policy statement is provided to the patient or authorized representative. ...” On January 2, 2025, review of facility policy titled “UPMC Clinical Guideline - Guidelines for Conducting Room Searches, Visitor Searches, and Personal Searches”. With a last updated date of August 6, 2025, stated “Purpose UPMC strives to provide a safe and healthy environment for patients, staff, and visitors. To facilitate a safe atmosphere, it is necessary at times to assess for the presence of contraband, drugs, and drug paraphernalia, and to provide appropriate disposition of such items. ... Definitions: Personal Search: A personal search is the act of searching a patient and their belongings for contraband, potentially dangerous, illegal, or other unauthorized items. It is conducted as needed and should be proportionate to the identified risk, minimizing intrusion into privacy and dignity. ... Contraband: Refers to any item that is normally legal to have but is not allowed in the hospital because it could pose a risk to patient safety or violate UPMC rules. This includes alcoholic drinks, any medicine (prescription or over the counter) that has not been approved by a hospital physician, and other items that may be safe elsewhere but may not be safe or legal in the hospital. ...” On January 5, 2025, review of facility document “Code of Conduct Smoking Prohibited While Receiving Treatment” with a last updated date of August 6, 2025, states “UPMC is committed to delivering quality medical care to the patients we serve. We seek to ensure the protection of each patient’s physical and emotional health and safety. It is our aim to provide quality medical services in an environment that respects each patient ’ s individuality and dignity. Part of your role as a patient is to cooperate with all hospital staff. You are responsible for following all hospital regulations, expectations, and guidelines. ... We know that it can be stressful to be a patient in the hospital. However, all UPMC hospitals are non-smoking facilities. If you smoke, your doctor can order an alternative to smoking such as patches, gum, medication, or other such treatments to assist you. Please inform your doctor or nurse if you are interested in a product to help you quit smoking or refrain from smoking during your hospital stay. If you leave the hospital to smoke for any reason, your physician may discharge you from the hospital. Additionally, please note that smoking is not permitted anywhere inside the hospital or on hospital property. This policy is in place to ensure the health and safety of all patients, visitors, and staff. Hospitals may have oxygen in the walls making smoking extremely dangerous. Smoking in the hospital may cause a fire and harm to you and others. We appreciate your cooperation in adhering to this policy. ... Staff signature below acknowledges that 1. I have reviewed the statements set forth above in this document with the patient. 2. I have ensured patient has a copy of the UPMC Patient Rights and Responsibilities. 3. I have explained that continued failure to comply with the responsibilities as outlined in the UPMC Patient Rights and Responsibilities may compromised the ability of UPJMC hospital to care for the patient. 4. A copy of this agreement will be placed in the patient ’ s medical record. Patient Signature below acknowledges that: I understand the UPMC Patient Rights and Responsibilities and agree to abide by the expectations outlined in the Agreement for the remainder of my visit with UPMC.” Signature line then follows. Review of MR1 revealed the patient was brought to the emergency department (ED) by an ambulance from the Greyhound bus stop, on December 20, 2025, at 2333, for complaints of abdominal pain. MR1 revealed documentation that the patient smokes cigarettes at a volume of one pack a day. Review of MR1 revealed there was no Code of Conduct Smoking Prohibited While Received Treatment in the medical record. Further review of MR1 revealed there was not a smoking assessment completed, and smoking paraphernalia was not removed. Continued review of MR1 stated on December 21, 2025, at 04:06 am, the patient was given discharge instructions by the nurse, and the patient asked a question which required the nurse talk to the provider. The Nurse was talking to the provider outside the patient room when a staff member yelled “fire, fire, the patients on fire.” Staff entered the room, and the fire was noted to be on top of the blanket. The staff put out the fire immediately. Patient was evaluated by provider, and no injuries or burns were found. Patient was then placed on a hold for a psychiatric evaluation and belongings were searched at which time 2 lighters were removed until discharge. Tour of the Emergency Department on January 2, 2026, at 9:45 AM revealed no signs posted that state “No Smoking” were found in Emergency Department entrance, registration, triage, waiting room, and ED rooms. Interview with EMP1 on January 2, 2026, at approximately 10:30 AM confirmed there were not any “No Smoking” signs present in the emergency department. Interview with EMP6 on January 2, 2026, at 10:15 AM, EMP6 stated if a patient comes through the Emergency Department via ambulance they are not searched unless there is a concern and then security would be called to do the search. If cigarettes or a lighter are found they would be put in a patient belongings bag and remain in the room with the patient. Interview with EMP7 on January 2, 2026, at approximately 10:30 AM, EMP7 stated that anything considered to be contraband they would confiscate. They are specifically looking for something that can cause physical harm to themselves or others. If cigarettes and lighters are found during a search, they leave it with the patient. Even though they are a smoke free campus, they are not considered contraband.”

“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: 21962 Based on a review of facility documents, medical records (MR), video observation, and employee interviews (EMP), it was determined the facility failed to follow their policy in monitoring a patient’s condition in one of ten medical records reviewed (MR1). Findings include: Review of facility policy “Restraints and Seclusion” with a review date of July 10. 2023, revealed “... III. 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 ... IX. Use of restraints or Seclusion for Violent of Self-Destructive Behavior (Previously identified as “Behavioral Management”) ... E. ONGOING PATIENT ASSESSMENT AND CARE INTERVENTIONS ... 4. Patients in restraint or seclusion for Violent or Self-Destructive behavior will be continuously observed and reassessed. The continued need for the use of restraints/seclusion will be reassessed and documented in the medical record at the following frequencies or more often as the patient condition requires. a. For Violent or Self-Destructive behavior - every 15 minutes ... F. DISCONTINUATION OF RESTRAINT/SECLUSION 1. The RN or physician, CRNP or PA may discontinue restraint/seclusion if the criteria for discontinuation have been met. 2. The time and criteria for release will be documented when the restraint is removed and/or seclusion discontinued ... “ Review of facility policy “UPMC Pinnacle Hospitals Nursing Standards of Care “revealed “I. Title: Unit Standard of Care for Emergency Dept Actions. II Goals/Expected Outcomes and Nursing Actions ... c. Ongoing assessment for medical patient: ... 6) Vital signs to be documented following the standards below for medical patients. During the course of treatment and evaluation in the ED ...b. ESI {Emergency Severity Index] 2 - at least q 1 hr [every hour] ...” Review of MR1 on August 12, 2024, revealed patient was brought in by police to the Emergency Department on July 28, 2024, at 12:40 AM with an admitting diagnosis of alcohol intoxication. At 1:11 AM the physician gave an order for one-to-one supervision and physical restraints. At 1:26 AM the physician ordered labs including ETOH (Ethanol - alcohol level). At 2:00 AM the patient’s Blood Alcohol Content (BAC) resulted in 379 mg/dl (over 400 is at risk for serious complications including coma and death). Partial restraints were released at 2:43 AM, and the last extremity was released at 3:30 AM from restraints. Restraint ordered discharged but one to one supervision order remained. At 4:38 AM the Physician wrote “... ETOH elevated at 379; will be sober around 1500 [3:00 PM] this afternoon but will monitor.” MR1 showed the patient was classified as an ESI 2 (emergency service index) which would result in vitals being monitored at least every hour. At 3:50 AM Registered Nurse documented that Oxygen saturation was at 87% on 2 liters of oxygen and patient was increased to 4 liters. At 4:10 AM Oxygen saturation decreased to 80% and patient oxygen was again increased to 6 liters of oxygen. At 7:07 AM the Registered Nurse entered the room and found the patient unresponsive. Emergency Medical code was started at 7:15 AM. Patient was pronounced dead at 7:31 AM. Further review of MR1 revealed that restraint monitoring was documented as completed at 1:45 AM, 2:00 AM, 2:15 AM, 2:30 AM, 2:45 AM, 3:00 AM, 3:15 AM, and 3:30 AM. On August 13, 2024, observation of video recording of the hallway directly outside the patient’s room on July 28, 2024, showed nursing exiting the patient room at 3:32 AM. During the time period that was documented in MR1 as the patient being observed and oxygen increased, no one was seen entering MR1’s room. Further review of the video revealed no nursing staff entering or exiting the room between 3:33 AM and 7:07 AM. Interview conducted on August 13, 2024, with EMP9 (physician) revealed that they were not made aware of the low oxygen saturation change in condition. Interview conducted on August 13, 2024, with EMP8 confirmed that no one entered the patient room to assess the patient or take vital signs according to policy. In addition, EMP8 confirmed that no one was assigned to the patient to provide the one-to-one observation per order and the video observation did not match what was documented in the medical record.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 21962 Based on review of facility documents, medical record (MR) and interview with staff (EMP), it was determined the facility failed to protect a patient from abuse in one of four medical records reviewed (MR1). Review on April 1, 2024, of facility policy “Patient Abuse Allegations” dated November 14, 2022, revealed ... I. POLICY: This policy outlines the responsibilities of healthcare providers in recognizing, treating, and reporting suspected cases of abuse and neglect of minors, persons with disabilities and the elderly. UPMC patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. This policy provides clinical guidance regarding the assessment of, and appropriate interventions indicated in cases of abuse or suspected abuse. II. PURPOSE: The purpose of this policy is to assure that patients shall be treated with consideration, respect and with full recognition of their dignity and individuality. Any suspected occurrence of abuse or neglect will be investigated promptly and, where appropriate, remedial action will be promptly taken. UPMC Pinnacle shall take reasonable measures to ensure that patients are not subject to abuse. ... IV. DEFINITIONS A. Abuse is the infliction of injury, unreasonable confinement, harassment, intimidation or punishment with resulting physical harm or pain, mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of patients, even those in a coma, cause physical harm or pain, or mental anguish B. Types of Abuse ... 5. Financial- The illegal or unauthorized use of a person’s property, money, pension, or other valuables ... 2. Special Considerations prior to starting the investigation ... e. If at any time the patient notifies the Police and the Police become involved with the investigation, the legal department will be consulted by the director of regulatory prior to beginning an investigation of abuse. (i) It is still recommended that an internal investigation occur even in situations when Police are involved. 3. Initial steps taken when alleged abuse is reported. a. The department supervisor who is made aware of the report of alleged abuse is responsible for: (i) Ensuring the patient is safe and communicating with the patient the steps that will be taken to investigate the concerns. (ii) The alleged event is entered timely into the incident reporting system. (iii) The alleged employee is notified of the reported abuse and is suspended until the investigation is completed. .... VI. DOCUMENTATION A. A file with a summary of the investigation and other significant reports and documents will be maintained by the Director of Regulatory. These files will contain evidence of the complaint, the investigation, the outcome of the investigation, follow-up communications with the patient or the patient ’ s legal representative and, where required, notification of the appropriate licensing or accreditation agencies ....” Review on April 1, 2024, of facility policy “Patient Rights/Organizational Ethics” dated December 20, 2023, revealed “... You have the right to: 1. Receive respectful care given by competent personnel in a setting that: ... c. is free from all forms of abuse, exploitation or harassment or neglect ...” A review on April 1, 2024, of MR1 revealed the patient was brought to the Emergency Department (ED) on January 22, 2024, for acute renal failure. The patient passed away at the hospital on January 25, 2024. Interview conducted on April 1, 2024, with EMP8 revealed the hospital was made aware by the police on March 14, 2024, that EMP9 was being investigated for an allegation of using a deceased patient’s (MR1) credit card. A review of the Staffing schedule revealed that EMP9 was on the staffing sheet and assigned on March 14, 2024, from 7:00 PM to March 15, 2024, 7:00 AM, following the facility being made aware of the allegation. On April 1, 2024, a request for the abuse investigation was made. No investigation was provided. Interview conducted on April 2, 2024, with EMP8 confirmed that the alleged theft of the credit card was financial abuse per the policy and that the employee worked a 12-hour shift after the facility was made aware of the allegation by the Police. Further interview confirmed that the facility did not conduct an abuse investigation.”