HospitalInspections.org

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 who eloped from the hospital for one of 20 medical records reviewed (MR1).


Finding include:

On December 11, 2024, a review of facility policy "Care Attendant Utilization and Observation of Patients", last reviewed February 2024, revealed the following: "Policy: ...UPMC will utilize Care Attendants when necessary to provide observation for patients on inpatient nursing units and in emergency department, in accordance with established standards. ... This policy outlines the role and responsibilities of the Safety Care Attendant and the Psychiatric Care Attendant. ... Safety Care Attendant: Provides patient care, support and constant observation in accordance with established policies and procedures under the direction of the RN/LPN, physician, or provider with prescriptive authority. Routinely performs ... constant observations, ... transfer and ambulation assistance, and patient comfort measures. Psychiatric Care Attendant: Provides constant observation or special constant observation to assigned suicidal or behavioral health patients under the direction of provider ... As a result, the Psychiatric Care Attendant will have limited direct care responsibilities so that the patient remains in direct eyesight or, as ordered, within arm's reach at all times. As a result, the Psychiatric Care Attendant may not complete other care or [activities of daily living] ADLs for the patient that would require the Psychiatric Care Attendant to leave the room (such as going to the patient's bathroom) or turn their back to the patient. ... Constant Observation (CO): Whereby the staff continuously observes and may interact individually with the patient while keeping the patient in sight at all times. Additionally, the patient's hands must be visible at all times to the CO staff or Care Attendant. ... Patients on CO status may have issues that jeopardize their safety or the safety of others. ... that require staff or a Care Attendant to be observing them at all times to ensure their safety. ... Psychiatric Care Attendant: The request of a psychiatric care attendant for suicidal or behavioral health patients requires the order of a physician. ... Discontinuation of a psychiatric care attendant can only be completed with a physicians order."

On December 11, 2024, a review of facility policy "Observation of Behavioral Health Patients", last reviewed July 2024, revealed the following: "It is the goal of UPMC McKeesport to ensure the safety of behavioral health patients seeking care and evaluation in the Emergency Department by protecting them from their self and others through close observation. ... The observer will document their observations on the Constant Observation Flowsheet, which is a print on demand document. 4. If the behavior of the observed patient indicates the possibility of them incurring imminent harm or eloping from the emergency department, the nurse or provider shall be immediately notified and UPMC Police/Security summoned as deemed appropriate. ... 6. The elopement of any behavioral health patient requires the immediate notification of the ED Charge Nurse, ED Leader or ED leader on-call, and provider to discuss the appropriate response."

On December 11, 2024, a review of facility policy "Restraint and Seclusion" last reviewed July 2024, was completed and revealed: "... 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."

Review of MR1 on December 11, 2024, revealed that the patient was a 39-year-old female with a history of psychiatric disorders, who arrived in the facility's Emergency Department (ED) for a psychiatric evaluation, on November 8, 2024, accompanied by police as an involuntary commitment (302) after concerned behavior at home. The patient was found in her apartment burning paper and was attempting to make a campfire. Further review of the medical record revealed that the patient was placed in a patient room due to the Columbia Suicide Severity Rating Scale. MR1 had positive thoughts for suicide and was completely undressed and placed in a green hospital gown. MR1 has a history of suicidal ideation, Bipolar illness, substance abuse, alcohol abuse, borderline personality disorder and abusive behavior to staff while in the hospital. MR1 eloped from the ED on November 9, 2024.

On December 11, 2024, a review of MR1 revealed a physician order was placed November 8, 2024, at 9:38 A.M. for a Psychiatric Care Attendant with constant observation. However, the facility was unable to provide documentation that constant observation occurred until November 9, 2024, at 7:00am, which was 21 hours after the order was placed.

On December 10, 2024, a review of surveillance video from the Emergency Department dated November 9, 2024, at approximately 8:27 PM, revealed the following:
At 8:27 PM, EMP4 [sitter] is seen seated across the hallway from the "quiet room", with a desk in front of their person. The doorway to the quiet room is ajar. MR1 emerges at approximately 8:28 PM. MR1 has a blanket draped over their head and shoulders, with hands wrapping the blanket to their chest. MR1 exits the room, past EMP4, with blanket in the same position. EMP4 stands and begins to follow MR1 past the nurses' station, as they progress down the corridor toward the exit. MR1 is seen shifting toward the side of the hallway where the exit is located and pauses in the doorway. EMP4 appears to shift, placing themselves in front of the patient. MR1 runs to the right of the surveillance view and EMP4 reaches to stop them, grasping the blanket. In the next piece of video, MR1 is seen running past an unattended security desk station through two sets of open automatic sensor doors.

The above was confirmed by EMP1 on December 11, 2024, at 1:00PM.