UPMC Presbyterian Shadyside

“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: 45574 Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to initiate a physician order for telemetry in one of 10 medical records revierwed (MR1). Findings include: On August 26, 2026, a review, of the policy, “Telemetry Monitor Policy” revealed, “It is the policy to provide standardized, consistent care of patients undergoing continuous cardiac rhythm monitoring. When a patient’s clinical condition warrants the need for cardiac monitoring, UPMC nursing will utilize the type of monitoring necessary... Interpretation of cardiac rhythm waveforms is the responsibility of trained personnel... Monitor Orders & Evaluation 1. A physician and/or will assess the need and provide the order for the cardiac rhythm monitoring. ...b. Monitor Association. 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 ... 4. Confirm monitor is in view in all necessary locations.” On August 26, 2026, a review of MR1 was completed and revealed that MR1 was admitted for observation from the emergency department on July 7, 2026, at 11:36 PM. ED nursing note, “Patient to 10 E/W with transport from ED; 2 RN skin assessment performed by this RN and Gen. RN: stage 3 noted on coccyx..” A third nursing note at the time of transfer revealed, “10 E/W charge established and reiterated non monitor orders with this RN informed no monitors available on 10 EW and any monitor orders would require transfer.” Further review of MR1 revealed that on July 8, 2026, at 12:52 AM, an order for cardiac monitoring was entered by the provider and acknowledged by the RN at 2:13 AM. The monitor was not placed. There was no evidence that either the charge nurse or AOD (Administrator on Duty) was made aware of the order. On July 8, 2026, at 6:08 AM, MR1 was found pulseless and apneic. ACLS protocol was initiated. MR1 expired on July 8, 2026, at 6:37 AM. On August 27, 2026, at 9:00 AM, EMP4 confirmed the above findings.”

“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 for one of ten medical records reviewed (MR4). Findings include: On August 21, 2025, a review of policy, HS-HD-AP-07, “Assessing Patient for Suicide Risk” was completed and revealed the following: I. POLICY/PURPOSE: It is the policy of UPMC to recognize the importance of screening & assessing for risk of suicide, initiate reasonable precautions to minimize the chance of a patient killing themselves and to create a safe environment... IV. Procedure: ...1. High Risk Patients (Bullet 3)Utilize a ligature resistant bathroom, and if not available, observe the patient while the patient is in the bathroom. (Bullet 4) Assess physical environment and remove contraband, including unsafe items not necessary for patient care... (Bullet 5) When appropriate, place patient in hospital attire. On August 13, 2025, a review of MR4 revealed a 70 year old male who was admitted to the hospital on June 30, 2025 with a diagnosis of suicidal ideation and the patient himself was asking for inpatient admission and asking for safety. MR4 reported that he had been very depressed for four months since his son and his dog suddenly died. He denied delusions but expressed that he had several plans for suicide and was worried for his safety. His suicide risk assessment was completed and he was scored as a high risk. He was on metoprolol, lisinopril, Atorvastatin, lasix and had a history of sleep apnea requiring CPAP. The facility document revealed on July 6, 2025, that while he was in the hospital, MR4 had a plan to hang himself from the CPAP supplies found in the bedroom as well as with the CPAP cords from the machine left in the room. In addition, a visitor found a baggie of crack in his room. The information was relayed to the hospital leadership and security and MR4 was changed into hospital clothing and remained in hospital clothing until the time of discharge. MR4 remained in the hospital for additional care and treatment. Interview with EMP1, at 1:10 PM, confirmed that the facility failed to remove unsafe items from the room as per policy. On August 13, 2025, at 1:15 PM, EMP1 confirmed the above.”

“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: 45574 Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to execute the admitting physician orders for implementation of continuous cardiac monitoring for one of fourteen medical records reviewed (MR1). Findings include: On January 2, 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 2, 2025, a review of MR1 revealed that MR1 was admitted on November 6, 2024, at 23:45. The admitting physician ordered continuous cardiac monitoring on November 7, 2024 at 00:40. Continuous cardiac monitoring was not initiated. On November 7, 2024, at 08:30, MR1 was found without a pulse. On January 2, 2024, the above findings were confirmed at 10:57 AM by EMP4 and EMP9.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 45574 Based on a review of facility document, medical records (MR), and employee interview(EMP), it was determined that the facility failed to obtain the Important Message from Medicare (IMM) in seven of ten medical records reviewed (MR3, MR4, MR5, MR6, MR8, MR13, and MR17) and facility failed to obtain the IMM within 2 calendar days in two medical records reviewed (MR7 and MR20). Findings include: On December 5, 2024, a review of Policy HS-QM0884, Medicare Hospital Issued Notices of Financial Liability and Discharge Appeal (Last Revised: December 20, 2023) was completed and revealed: “ C. important Message from Medicare (IMM): 1. All Medicare/Medicare Advantage plan enrollees who are hospital inpatients must receive the IMM ... 3. The IMM must be delivered within 2 calendar days of admission, must obtain the signature of the beneficiary or his/her representative, and a copy must be provided to the beneficiary/representative. Hospitals will also delivery a copy of the signed notice as far in advance of discharge as possible, but not more than 2 calendar days before discharge. “ On December 5, 2024, a review of MR3 (admitted: November 29, 2024) revealed that the MR3 was covered by a Medicare Advantage Plan and there was no admission IMM located on the chart. On December 5, 2024, a review of MR4 (admitted: December 2, 2024) revealed that the MR4 was covered by a Medicare Advantage Plan and there was no admission IMM located on the chart. On December 5, 2024, a review of MR5 (admitted: August 15, 2024/ discharged November 20, 2024) revealed that the MR5 was covered by a Medicare Advantage Plan and there was no admission IMM located on the chart. On December 5, 2024, a review of MR6 (admitted: November 30, 2024) revealed that the MR6 was covered by a Medicare Advantage Plan and was no admission IMM located on the chart. On December 5, 2024, a review of MR7 (admitted: October 27, 2024; expired November 7, 2024) revealed that the patient was covered by a Medicare Advantage Plan. The admission IMM was completed on November 1, 2024, 5 calendar days following admission. On December 5, 2024, a review of MR8 revealed that the patient was covered by a Medicare Advantage Plan but there was no admission IMM located on the chart. On December 6, 2024, a review of MR13 (admitted: November 29, 2024) revealed that the MR13 was covered by a Medicare A and B but there was no admission IMM located on the chart. On December 6, 2024, a review of MR17 (admitted: October 31, 2024) revealed that the MR17 was covered by a Medicare and B but there was no admission IMM located on the chart. On December 6, 2024, a review of MR20 (admitted: October 31, 2024) revealed that the MR20 was covered by Medicare A and B. There admission IMM was completed on 11/28/2024, 28 calendar days following admission. The above findings were confirmed on December 6, 2024, by EMP1 and EMP2 between 8: 29 AM and 10:27 AM.”

“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 staff interview (EMP), it was determined that the facility failed to document on-going reassessment of the patient every two hours in five of eleven restraint medical records (MR2, MR7, MR8, MR13, and MR17). Findings include: On December 5, 2024, at 12:26 PM a review of Policy HS-NA0416, “Restraints and Seclusion” (Last Revised: July 30, 2024) was completed and revealed: “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 with not be limited to: a. Release of restraint b. Color, sensation and movement of the involved extremity c. Skin integrity/signs of injury d. Readiness for restraint discontinuation based on observed behaviors e. Alternatives provided to the patient.” On December 5, 2024, a review of MR2 revealed that restraints were initiated on December 2nd, 2024, at 9:00 AM in the Emergency Department. On December 2, 2024, at 1:00 PM the facility failed to document an assessment or reassessment for continuing restraints, as per facility policy. On December 5, 2024, a review of MR7 revealed that restraints were initiated on November 3, 2024, at 8:00 AM. There was no evidence of reassessment at 10:00 AM, 12:00 PM, 2:00 PM, and 4:00 PM. On November 5, 2024, restraints were reinitiated and included the left upper extremity, right upper extremity, chest and waist. There was no evidence of reassessment on November 6, 2024, at 8:00 PM and 10:00 PM. On December 5, 2024, a review of MR8 revealed that restraints were initiated on November 17, 2024, at 8:05PM. Reassessment was not completed on November 19, 2024, at 02:00 AM. Restraints were discontinued on November 20, 2024 at 07:15 AM. Restraints were reinitiated on November 20, 2024 at 08:00 PM. On November 23, 2024, the 6 AM reassessment was not completed. On November 24, 2024, the 12:00 AM assessment was not completed. On November 27, 2024, the 10:00 PM reassessment was not complete. On December 6, 2024, a review of MR13 revealed that soft wrist restraints were initiated on November 29, 2024, at 8:50 PM. On November 30, 2024, the 8:00 PM reassessment was not completed. On December 6, 2024, a review of MR17 revealed that soft wrist restraints were initiated on November 08, 2024, at 8:00 PM. On November 9, 2024, the 6:00 PM reassessment was not completed. On November 13, 2024, the 2:00 AM, 4:00 AM, and 6:00 AM reassessments were not completed. Restraints were discontinued on November 14, 2024, at 08:00 PM and reinitiated on November 15, 2024, at 8:00 AM. On November 16, 2024, the 6:00 PM reassessment was not completed. The above findings were confirmed by EMP3 on December 6, 2024, between 8:30 AM and 10:19 AM.”

“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: 27429 Based on document review and staff interview (EMP), it was determined that the facility failed to maintain electrical wiring systems and equipment in one instance reviewed. Findings include: A review of documentation revealed an extension cord used to power an ice machine in the 4N cafe caught on fire on December 3, 2023, at 3:40 p.m. Further review revealed that the fire was immediately extinguished, the cord was removed, and a sweep of the hospital revealed there were no other extension cords in use. Interview with EMP1 on December 6, 2023, at 2:50 p.m., confirmed the misuse of electrical wiring.”