HospitalInspections.org

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to develop and implement procedures to prevent patients from acquiring and using illicit drugs for one of ten medical records reviewed (MR1).


Findings include:


1. A review of the facility policy, "Patient Rights and Responsibilities, effective February 2016," revealed, "5. Comply with the doctor's or doctors' medication treatment plan for this hospital stay or encounter...Refrain from using illicit drugs or any medication or supplement not ordered by your doctor during this hospital stay or outpatient encounter..."

A review of the facility' "Notice of Non-Compliance" form was reviewed on June 28, 2022, and included the following, "The following behavior is/were observed by our staff ... Using alcohol, illegal drugs or tobacco in the clinical environment...leaving the unit against medical advice...."

A review of MR1 on June 27, 2022, and revealed the patient signed a Notice of Non-Compliance form dated June 20, 2022, at 5:50 PM.

A review of MR1's History and Physical (H&P) dated June 19, 2022, revealed the patient had diagnoses that included poorly controlled type 2 diabetes, history of stroke, seizure disorder, end stage renal disease on hemodialysis three times per week, chronic pain on opioids, and generalized anxiety disorder who presented with low blood sugar and confusion. The H&P revealed that the patient self-administered his medications, recently had pain medications increased by physician, but was unsure exactly how much of each medication he to take. According to the H&P MR1 was crashed his car while driving on June 17, 2022.

A nurse's note in MR1 dated June 20, 2022, at 5:50PM revealed that the patient signed a Notice of Non-Compliance form to go off the floor and to the cafeteria.

A nurse's note in MR1 dated June 20, 2022, at 9:45 PM revealed the patient "went outside at 20:30, returned at 21:20...This nurse assessed patient at time of return. Patient alert and making jokes. Blood sugar checked and found to be high. Left room to page physician. When returned patient not responding. Condition called."

A general medicine progress note in MR1 dated June 21, 2022, revealed that a Condition C was called overnight for unresponsive episode. Patient speaking with nursing then on return found unresponsive with pinpoint pupils and bradypnea [slow respiratory rate]. [Respiratory rate documented in record as 2 breaths per minute]. Patient given Narcan with significant improvement in mental status and breathing. The police search MR1's room and found fentanyl. Later the patient admitted to doing heroin while off the unit.

During an interview on June 27, 2022, at 2:55 PM, EMP5 confirmed that MR1 signed a Notice of Non-Compliance form. EMP5 also stated, "I don't worry about my patients" once they sign the form.

During an interview on June 28, 2022, at 8:00 AM, EMP7 stated that while passing medications on June 20, 2022, at 8:20 PM, EMP7 heard MR1 tell another nurse he was leaving the unit and was not concerned because MR1 signed a Notice of Non-Compliance form.


During an interview on June 27, 2022, at 1:20 PM, EMP4 could not speak to any process the facility has to prevent patients from leaving the unit to obtain illicit drugs. EMP4 referred to a process from another campus that had not been implemented at this facility. During the interview EMP4 further stated, "This is a multifactorial issue...increasing awareness on the front line...measuring, looking, watching...provide an escalation pathway...we have not used our internal resources."

Based on a review of facility documents, medical records review (MR), and staff interview (EMP), it was determined the facility failed to ensure nursing personnel followed facility protocols and policies for patients ordered cardiac monitoring for two of ten medical records reviewed (MR1 and MR8).


Findings included:


1. On June 28, 2022, a review of the policy, "Nurse Driven Cardiac Monitor Protocol dated June 1, 2021, revealed, "With a physician's order, the nurse may determine the appropriateness of continuing or discontinuing the cardiac monitoring if the patient meets criteria as per the Nurse Driven Cardiac Monitor Protocol... V. Procedure ...1. A physician's or Advanced Practice Provider's (APP) order is required ...4. If patient does not meet continuation criteria, the nurse will select, "Discontinue monitor and cardiac monitoring order," remove the cardiac monitor from the patient, and discontinue the original cardiac monitor order using the communication type, "Protocol" and choosing the Attending Physician's name. The protocol communication-type order is then routed to the physician's in-box for authentication."


On June 28, 2022, the facility's Centralized Telemetry Unit (CTU) Workflow Quick Reference document was reviewed and revealed the following: "Blue Alarms-Unit staff to assess and manage Blue alarms independently...CTU will call nurse immediately when a patient has a blue 'Leads off ' alarm and is no longer being monitored ...Monitor Standby-Nurse calls the CTU to request to place patient on Standby...Nurse will specify where the patient is going, specifically if the patient is going to an out-of-scope area (Cath Lab, Cardioversion, etc.)."


A review of MR1 on June 27, 2022, revealed a physician's order dated June 19, 2022, "Admit to Inpatient, Monitored Bed."


A nurse's noted in MR1 dated June 20, 2022, at 5:50 PM, revealed the patient "signed noncompliance paper to go off the floor to cafeteria."


During an interview on June 27, 2022, at 2:55 PM, EMP5 stated MR1 left unit on June 20, 2022, at 5:50 PM, and the patient's cardiac monitor stopped monitoring. EMP5 confirmed she was not concerned that MR1 went to the cafeteria unmonitored because "I figured if something happened to him, there were enough personnel around."


During an interview on June 27, 2022, at 4:15 PM, EMP 6 confirmed CTU had documentation that MR1 was off the monitor on June 20, 2022, at 6:00 PM, and back on at 6:47 PM. There was no documentation that CTU staff notified the nursing unit per policy, and no documentation that the unit nurse notified CTU to place patient on standby.


During an interview on June 28, 2022, at 8:15 AM, EMP8 confirmed per record review, MR1 had an order for cardiac monitoring and no order to discontinue it.


2. On June 27, 2022, a review of facility document titled UPMC Shadyside Centralized Telemetry Unit (CTU) Workflow Quick Reference Overview and Talking Points, not dated, revealed, "...Standby...Pt goes on standby without call-CALL RN, DOCUMENT PHONE CALL...Blue Alarm Equipment Alarms Blue Alarm-Let the PCT know if there is a lead off to reapply it next time they are in the room Document phone call Continue to monitor EXCEPTION: BE AWARE, EQUIPMENT NOT CONNECTED TO PATIENT IS A BLUE ALARM. CALL THE RN AND TELL THEM THE PT IS NOT BEING MONITORED... Blue Alarms Unit Staff to assess and manage Blue Alarms independently..."

A review of MR8 on June 27, 2022 revealed that the patient was admitted June 19, 2022, and eloped later that day on June 19, 2022.

A review of MR8's Discharge Summary dated June 19, 2022, at 4:30 PM, revealed, "Per nursing, patient was alert and oriented x3 and aware of need for further evaluation, however, mentioned multiple times that he's going to leave the hospital. Refused treatment and testing. Patient eloped this morning prior to rounds."

A review of MR8's CTU log for the patient monitor on June 19, 2022, after 10:37AM medications reviewed the following:
10:44am "ECG Leads Off Generated at 10:44:01," 10:44am "ECG Leads Off Ended," 10:47am "Remind," 10:50am "Remind," 10:53am "Remind," 10:53am "Silence," 10:56am "Remind," 10:59am "Remind," 11:02am "Remind," 11:06am "Remind," 11:09am "Remind," 11:09am "Silence," 11:12am "Remind," 11:12am "Silence," 11:12am "Arrythmia Off," 11:12am "Equipment in standby," 11:12am "ECG Leads Off Ended," 11:12am "Equipment Offline," 11:35am "Patient Update," 11:35am "Pacer algorithm set to Pacer Algorithm Off," 1:41pm "Patient Discharge."

During an interview on June 28, 2022, at 12:00 PM, EMP6 confirmed there was no record of CTU calling the floor to alert staff to patient being off of monitor.

During an interview on June 28, 2022, at 1:50 PM, EMP2 confirmed the above findings in the medical record.