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UPMC PRESBYTERIAN SHADYSIDE
PATIENT RIGHTS: NOTICE OF RIGHTS
Tag No.: A0117
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
Tag No.: A0167
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.