HospitalInspections.org

Based on a review of facility documents, and staff interview (EMP), it was determined the governing body failed to ensure the services of a registered dietician via the Master Services Agreement dated October 1, 2024.


Findings include:


On March 19, 2025, a review of the Master Services Agreement (dated October 1, 2024) between UPMC Washington and UPMC Greene was reviewed and revealed: "1. Provision of Services 1.1 UPMC Washington agrees to provide to UPMC Greene the services and personnel described in the attached Appendices pursuant to the terms and conditions of this agreement."


On March 19, 2025, a review of "Appendix B" of the Master Services Agreement- "UPMC Washington Services/Employees Provided to UPMC Greene Under This Agreement was completed and revealed the following services are provided to UPMC Greene from UPMC Washington:1. Nursing; 2. PT/OT/ST; 3. Medical Director; 4. Medical Office Staff; 5. Human Resources; 6. Employee Health; 7. Radiology; 8. Laboratory; 9. Infection Control; 10. Marketing; 11. Foundation/Volunteers; 12. Patient Experience; 13. Cardiac Diagnostics; 14. Administration; 15. Registration; 16. Information Technology; 17. Respiratory Care; 18. Case Management; 19. Medical Records; 20. Quality/Performance Improvement; 21. Materials Management; 22. Pharmacy; 23. Emergency Preparedness; 24. Police (as of 1/15/2024)."

On March 19, 2025, at 3:11 PM, EMP1 confirmed that the dietician was not included in the Master Services Agreement; however, may be included in the Cura Hospitality, LLC contract (executed July 27, 2020). A review of the Cura Hospitality Agreement was completed and revealed in " Section 10.4 " that all employees have an " Independent Contractor Relationship: Employees of the Company (Cura) are not, nor shall they be deemed to be, employees of the client (Washington Health System). Employees of the client are not, nor shall they be deemed to be, employees of Company."

On March 18, 2025, at 10:00 AM, EMP9 stated that EMP9 "could not recall the last time EMP9 had been to UPMC Greene."

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to document the ongoing assessment of the patient in restraints every two hours in one of four restraint medical records (MR11).

Findings include:


On March 17, 2025, a review of Restraint and Seclusion Policy (Last Approved: 04/08/2024) was completed and revealed the following: "Monitoring: C. At a minimum, the following parameters are assessed and documented as indicated: Non Violent and Non Self Destructive Restraint: Hygiene needs- Every two hours; Food/fluid needs- Every two hours; Skin condition/skin care/circulation- Every two hours; Reassessed: Restraints continued as ordered- Every two hours; Removed restraints- Every two hours; Mental Status- Every two hours; Cognitive functioning- Every two hours."


On March 17, 2024, a review of MR11 was completed. On January 25, 2025, MR1 was placed in non violent- non self-destructive wrist restraints. Orders were written by the LIP on January 25, 2025 at 11:00 PM; January 26, 2025 at 2:00 PM; and January 27, 2025 at 12:11PM when MR11 was placed in a canopy bed. There is no evidence of the required two hour documentation from January 26, 2025 at 6:00 PM until MR11 discharged on January 27, 2024 at 2:20 PM. Thus, MR1 was not re-assessed for 20 hours while in nonviolent restraints. There is no evidence in the medical record that the restraint was discontinued.

On March 17, 2025, at approximately 1:15 PM, EMP6 confirmed that a canopy bed was considered a restraint in the facility. In addition, EMP6 confirmed that there was no evidence of the required every two hour reassessments from January 26, 2025 at 6:00 PM until January 27, 2025 at 2:20 PM.

Based on a review of facility documents, credential files (CF) and staff interview (EMP), it was determined that the facility failed to adhere to the Medical Staff Bylaws during the credential process in assigning the appropriate Medical Staff category for nine of nineteen credential files reviewed (CF11, CF12, CF13, CF14, CF15, CF16, CF17, CF18, and CF19).


Findings include:


On March 18, 2025, a review of the Medical Staff Bylaws (Last Approved: December 12, 2023) was completed and revealed the following: "Credentials Policy: 2.A Active Staff; 2.A.1: Qualifications: The active staff shall consist of Medical Staff Members who meet the General Qualifications for Membership as established by these bylaws. 2.B. Associate Staff; 2. B.1. Qualifications: The Associate Staff shall consist of members who are in the process of becoming eligible for appointment to the Active Staff and who meet all other qualifications of Active Staff appointment. Upon completing one year on the Associate Staff, individuals who meet all the Active Staff qualifications shall be automatically transferred to Active Staff. 2.C. Courtesy Staff; 2.D. Coverage Staff; 2.D.2. Prerogatives and Responsibilities: (a) shall assume all functions and responsibilities to provide coverage for the other members of their coverage group, including ...emergency services and consultations ...2F Affiliate Staff; 2G Honorary Staff...".


On March 18, 2025, a review of CF11 was completed and revealed, in a letter dated January 15, 2025, ..."approved by the board on December 12, 2024 for the 'Moonlighting' category."


On March 18, 2025, a review of CF12 was completed and revealed, in a letter dated January 3, 2025, ... "approved by the board on December 12, 2024 for the 'Moonlighter Staff' category in the Department of Medicine."


On March 18, 2025, a review of CF13 was completed and revealed, in a letter dated January 3, 2025, ... "approved by the board on December 12, 2024 for the 'Moonlighter Staff ' category in the Department of Medicine."


On March 18, 2025, a review of CF14 was completed and revealed, in a letter dated January 3, 2025, ..."approved by the board on December 12, 2024 for the 'Moonlighter Staff ' category in the Department of Medicine."


On March 18, 2025, a review of CF15 was completed and revealed, in a letter dated January 3, 2025, ... "approved by the board on December 12, 2024 for the 'Moonlighter Staff ' category in the Department of Medicine."


On March 18, 2025, a review of CF16 was completed and revealed, in a letter dated January 3, 2025, ... "approved by the board on December 12, 2024 for the 'Moonlighter Staff ' category in the Department of Medicine."


On March 18, 2025, a review of CF17 was completed and revealed, in a letter dated January 3, 2025, ..."approved by the board on December 12, 2024 for the ' Moonlighter Staff ' category in the Department of Medicine."


On March 18, 2025, a review of CF18 was completed and revealed, in a letter dated January 3, 2025, ... "approved by the board on December 12, 2024 for the ' Moonlighter Staff ' category in the Department of Medicine."


On March 18, 2025, a review of CF19 was completed and revealed, in a letter dated January 3, 2025, ... "approved by the board on December 12, 2024 for the ' Moonlighter Staff ' category in the Department of Medicine."


On March 18, 2025, at approximately 10:30 AM, EMP11 acknowledged that the "Moonlighter Staff" category was not defined in the Medical Staff Bylaws.

Based on a facililty tour, document review, and staff interview (EMP), it was determined that the facility failed to ensure unauthorized access, and maintain condition of the walls in the dry food storage closet of the Nutritional Food Services Department.


Findings include:


On March 17, 2025, at 10:00 AM, a tour of the first floor therapy pool room revealed a fire exit door that was ajar and would not latch when properly closed.

A review of facility policy "Door Wedge Policy", last revised and approved on October 7, 2024, states "... B. Doors to stairwells, fire exits, smoke doors, and hazardous locations such as soiled utility rooms shall remain closed and latched at all times, unless equipped with hold-open magnets that release the door upon fire alarm activations ..."

An interview with EMP5 on March 17, 2025, at 10:05 AM, confirmed the unsecured entrance.


On March 17, 2025, at 10:05 AM, a tour of the Nutritional Services Department revealed areas in the dry food storage closet where paint was lifting away from the cement block, creating bubbles and large paint chips hanging from the walls.

Observation occurred at approximately 11:15 AM, during tour of the food preparation area with EMP3, EMP7, and EMP15.