HospitalInspections.org

Based on a review of facility documentation, medical record (MR) review, and staff interview (EMP), it was determined the facility failed to ensure patients were informed of their rights prior to receiving care for four of four outpatient medical records reviewed (MR1, MR2, MR3, and MR4).


Findings include:


On September 20, 2023, a review of the facility policy, Patient Rights/Organizational Ethics, Subject Patients' Notice and Bill of Rights and Responsibilities, Date: January 4, 2021, revealed, "II. Scope This policy applies to the United States based UPMC acute care hospitals, acute inpatient rehabilitation facilities, licensed outpatient clinics (hospital based)...III. Purpose The Patients' Notice and Bill of Rights and Patient Responsibilities is made available to patients, their family members and representatives via patient information materials and postings...VII. Patient Responsibilities...Patients are asked to assume the following responsibilities:...6. Comply with UPMC's smoke-free policy. UPMC maintains a smoke free environment to protect the health of patients, visitors, and staff. Smoking is not permitted on any UPMC property, including buildings, parking lots, and parking garages. You may not smoke in vehicles while on UPMC property. UPMC can provide you with information and strategies to help you quit smoking. If interested, please contact your nurse or team member."

On September 19, 2023, a review of the facility Patient Rights and Responsibilities booklet provided to patients revealed, "Patients are asked to assume the following responsibilities:...6. Comply with UPMC's smoke-free policy. UPMC maintains a smoke free environment to protect the health of patients, visitors, and staff. Smoking is not permitted on any UPMC property, including buildings, parking lots, and parking garages. You may not smoke in vehicles while on UPMC property. UPMC can provide you with information and strategies to help you quit smoking. If interested, please contact your nurse or team member."

On September 20, 2023, a review of MR1 revealed a date of service of September 15, 2023. Further review of MR1 lacked evidence that this patient was provided the Patient Rights and Responsibilities booklet or was informed of their rights and responsibilities prior to receiving treatment.

On September 20, 2023, a review of MR2 revealed a date of service of September 15, 2023. Further review of MR2 lacked evidence that this patient was provided the Patient Rights and Responsibilities booklet or was informed of their rights and responsibilities prior to receiving treatment.

On September 20, 2023, a review of MR3 revealed a date of service of September 15, 2023. Further review of MR3 lacked evidence that this patient was provided the Patient Rights and Responsibilities booklet or was informed of their rights and responsibilities prior to receiving treatment.

On September 20, 2023, a review of MR4 revealed a date of service of September 19, 2023. Further review of MR4 lacked evidence that this patient was provided the Patient Rights and Responsibilities booklet or was informed of their rights and responsibilities prior to receiving treatment.

During an interview on September 20, 2023, at 9:07 AM, EMP2 confirmed the above.