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Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure patients were notified of their rights in advance of receiving care for 13 of 14 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR9, MR10, MR11, MR12, MR13, and MR14).

Findings include:

On September 1, 2022, a review of the facility policy titled, "Admission of a Patient," dated: "October, 2021," revealed, "Purpose: To perform a baseline patient assessment, orient the patient to the hospital environment...Procedure:...11. Orient patient to hospital routines and provide an admission packet...K. complete the admission assessment..."

A review of the patient welcome packet was completed on August 31, 2022, and revealed a booklet that included patient rights and responsibilities.

Each patient electronic medical record (EMR) included a screen titled, "Admission General Information." This screen included a section titled, "Environmental Orientation," and listed "Admission packet given and reviewed," among other items such as fire/safety procedure, bathroom location, bed controls. This screen had a box next to each item where the nurse would check the box electronically to indicate the items were reviewed with the patient during the admission assessment.

On September 1, 2022, a review of medical records was completed and revealed the following:

MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR9, MR10, MR11, MR12, MR13, and MR14 were all patients who were admitted to either inpatient or outpatient care. None of these records included evidence that the patients were given and reviewed their admission packets that included their patient rights prior to receiving care.

During an interview on September 1, 2022, at various times during each medical record review, EMP 8 and EMP 5 confirmed that nursing failed to document that patient rights were provided and reviewed at the time of admission for MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR9, MR10, MR11, MR12, MR13, and MR14.

Based on a review of facility documents and staff interview (EMP), it was determined the facility failed to ensure patients were notified of the resolution to their grievances for two of four grievances reviewed (MR 7 and MR 8).

Findings include:

On September 1, 2022, the facility policy titled, "UPMC McKeesport Patient Complaint and Grievance Management, dated January 2022. The policy revealed, "V. Definitions:...D. Initiating a Grievance: If a patient complaint cannot be resolved at the time of the complaint, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint automatically becomes a grievance. the grieving party does not need to file a grievance...2. Complaints of Abuse and CMS Requirements: All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purposes of these requirements."


On September 1, 2022, a review of complaints and grievances was completed and revealed the following:

1. On May 3, 2022, EMP 2 was notified by a private physician's office that MR 7 alleged physical abuse while a patient at the facility during an admission in November 2021. Though there was documentation that the facility notified the patient to obtain his allegations, the investigative packet lacked evidence of a letter of resolution to the patient after the investigation was complete.

2. On March 21, 2022, a patient reported that, "she was inappropriately touched by staff when she was admitted..." There is documentation that there was an internal investigation resulting in the suspension of one employee. In addition, there is documentation that the local police were called and assumed responsibility for the investigation. There is no documentation surrounding the investigation by the local police department or the complete internal investigation by the facility. The file lacked evidence of a letter of resolution to the patient or a completed investigation.


On August 31, 2022, at approximately 1:35 PM, EMP 1 stated that once it was a police matter it was "out of their hands." EMP1 continued, "We made the decision not to send a letter."

During further interview on September 1, 2022, at 1:40 PM, EMP 1 confirmed the facility failed to follow their own complaint/grievance policy, and confirmed neither MR 7 or MR 8 were sent letters of resolution following their filing a grievance regarding allegations of abuse while a patient at the facility.

Based on review of facility policy, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that orders for use of restraints were properly followed for one out of four restraint medical records reviewed (MR6).

Findings include:

On September 1, 2022, review of facility policy titled, "Restraint and Seclusion", dated July 1, 2022, revealed "...VIII. USE OF RESTRAINT FOR NON VIOLENT/NON SELF-DESTRUCTIVE BEHAVIOR...A physician order, order of a CRNP or order of a PA is required for restraint use...".

A review of MR6, completed on September 1, 2022, revealed an order for mitt restraints ordered on 8/10/22 at 4:08pm with a stop date and time of 8/11/22 at 11:59pm. Upon review of restraint documentation, all documentation failed to address mitt restraints.

EMP8 confirmed these findings on September 1, 2022, at 11:15am.

Based on review of facility policy, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure accurate documentation of the condition and status of a restrained patient for one of four medical records revealed (MR3).

Findings include:

On September 1, 2022, review of facility policy titled, "Restraint and Seclusion", dated July 1, 2022, revealed "...III. DOCUMENTATION...Appropriate documentation is to be made for each patient placed in restraint...".

A review of MR3 completed on September 1, 2022, revealed the following:
An order for mitt restraints ordered on 08/26/22, at 6:50AM and canceled on 08/26/22, at 7:20PM.
Reassessments completed every two hours per policy.
On 08/26/22 at 12:00pm Restraint Reassessment Non Violent Form: "Time Restraint Discontinued* 8/26/2022 1917" "Restraint Activity* Discontinued from restraint or seclusion"; 2:00pm Restraint Reassessment Non Violent Form: "Time Restraint Discontinued* 8/26/2022 1917" "Restraint Activity* Discontinued from restraint or seclusion"; 4:00pm Restraint Reassessment Non Violent Form: "Time Restraint Discontinued* 8/26/2022 1917" "Restraint Activity* Discontinued from restraint or seclusion"; 6:00pm Restraint Reassessment Non Violent Form: "Time Restraint Discontinued* 8/26/2022 1917" "Restraint Activity* Discontinued from restraint or seclusion".
Patient was in restraints throughout the documentation and reassessments.
During an interview on September 1, 2022, at 11:00AM. EMP8 confirmed that patient was in restraints despite the documentation on the reassessment forms.