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Based on a review of facility policy and medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure the use of restraints was documented in a patient plan of care for one of four medical records reviewed (MR32).

Findings include:

Review of facility policy "Restraint and Seclusion" reviewed February 2016, ... "C. Patient Plan of Care: 1. The use of restraint and patient safety will be addressed in the patient's plan of care and/or treatment plan. ... ."

1) Reveiw of MR32 on March 3, 2016 at aproximately 11:00 AM, revealed the patient was placed in restraints on March 2, 2016 at 12:13 PM. Further review of MR32 failed to reveal documentation of restraint use in the plan of care.

2) During interview with EMP3, March 3, 2016 at approximately 1:30 PM, EMP3 verified the above findings.

Based on a review of facility policy and documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the condition of a patient in restraints was monitored by a physician, other licensed independent practitioner or trained staff at an interval determined by hospital policy for one of four medical records reviewed (MR33).

Findings include:

Review of facility policy "Restraint and Seclusion" reviewed February 2016, ... . "Ongoing Patient Assessment and Care Interventions: ... 4. There continued use of restraints for Non-Violent /Non Self-Destructive behavior will be reassessed and documented in the medical record at the following frequencies of more often as the patient condition requires. a. Non-Violent/Non Self-Destructive behavior-every 2 hours... ."

1) Reveiw of MR33 on March 3, 2016, at approximately 11:30 AM revealed the patient was in restraints on February 29, 2016, and March 1, 2016, further review of the medical record failed to note assessment documentation on February 29, 2016, from 2:00 AM to 8:00 AM and also failed to note assessment documentation on March 1, 2016, from 4:00 AM to 8:00 AM.

2) During interview with EMP3, March 3, 2016 at approximately 1:30 AM, EMP3 verified the above findings.

Based on review of facility policy and documentation and staff interview (EMP), it was determined that the facility failed to determine the scope of corrective actions implemented, and failed to monitor and evaluate implemented corrective actions to determine their effectiveness for one of three events reviewed.

Findings include:

Review of facility policy and procedure "Patient Safety Plan," dated March 25, 2015, revealed, " ...V. Summaries of Key Elements of Patient Safety Program: ...3. The Patient Safety Officer in collaboration with other members of one or more Peer Review bodies shall analyze recommended Process Improvements and determine the scope and timing of any Corrective Actions to be implemented by the Hospital. 4. The Patient Safety Committee or other designated Peer Review body shall monitor and evaluate implemented Corrective Actions on an ongoing basis to determine their effectiveness."

1. Review of facility documentation "Adverse Event Analysis Tool" dated October 2, 2015, revealed an investigation of a serious event with no documentation in the column "what other areas of the hospital may be at similar risk."

2. Interview with EMP4 on March 4, 2016, at 11:00 am revealed, "We didn't look at other areas of the hospital."

3. A request was made for documentation of the Action Plan for the above event, including audits. However, the facility was unable to provide the requested documents.

4. Interview with EMP14 on March 4, 2016, at 11:05 am revealed, "I didn't document my audits."

Based on a tour of the facility and staff interviews (EMP), it was determined that the facility failed to ensure all compounding, packaging, and dispensing of drugs and biologicals occurred under the supervision of a pharmacist and performed consistent with State and Federal laws.

Finding include:

A tour of UPMC Indiana Cancer Center on March 3, 2016, at 11:00 am revealed that the location did not have a pharmacist on staff for the supervision of compounding, packaging, and dispensing of drugs and biologicals.

On March 4, 2016, at 1:30 pm the facility was not able to provide a policy for the provision of pharmaceutical services at the aforementioned location.

An interview with EMP9 on March 3, 2016, at 11:15 am confirmed that the facility failed to ensure all compounding and dispensing of drugs and biologicals occurred under the supervision of a pharmacist.

An interview with EMP3 on March 4, 2016, at 1:30 pm confirmed that the facility failed to ensure all compounding and dispensing of drugs and biologicals occurred under the supervision of a pharmacist at the facility's off site location.

The Physical Environment Condition was found to be out of compliance during a Life Safety Survey completed on March 17, 2016. Further details are outlined in that Division of Life Safety Survey Report.

Based on a tour of the facility, observation and staff interview (EMP), it was determined that the facility failed to ensure a system was in place to maintain a sanitary hospital environment.

Findings include:

Review of facility policies "Laundering of mops and cleaning cloths," and "Laundering of Cubicles and Shower Curtains," revealed no documentation of procedures to separate clean and dirty textiles.

Review of "UPMC Job Code Description Job Title: ... Anesthesia Technician II ... Provides support for surgical cases by assisting in the preparation and maintenance of patient monitoring devices and anesthesia delivery systems before and during anesthesia."

Review of facility documentation "Unit Based Equipment Cleaning Grid Unit__ Anesthesiology Equipment 1. Anesthesia Machines workstations ... Frequency beginning each day Responsibility Anes. [anesthesiology] technician."

Review of facility policy and procedure "Operating Room" dated February 2015, revealed "Daily/Routine Between Case Cleaning: ...Clean the floor, including the baseboards, giving special attention to move equipment away from walls."

Review of facility "Infection Prevention/Control Plan" dated November 24, 2015, revealed "Work Practice Infection Control Monitoring ... 6. Each department will be responsible to maintain records of its own environmental surveillance."

1. Observation of the ground floor laundry room on March 2, 2016, at 10:30 am, revealed a bin of dirty mop heads next to a washing machine with mop heads in the wash cycle. Further observation revealed a clothes dryer next to the washing machine with clean cubicle curtains in the drying process.

2. Interview with EMP12 confirmed the findings and stated, "That is how we have always done the laundry."

3. Tour of the GI (gastrointestinal) lab room three and four revealed dust on top of the anesthesia cart and the rim of the monolithic floor.

During the tour EMP2 and EMP15 confirmed the above findings and revealed, "I see."

4. Interview with EMP15 on March 1, 2016, at approximately 9:30 AM during the tour of the GI Labs revealed "that would be anesthesia." Further interview on March 4, 2016, at approximately 1:05 PM revealed, "We would follow the OR (operating room) policy for the floor."

5. During a tour of the fluoroscopy room revealed a large amount of dust on top of the CT(computerized tomography) scanner and the vent in the patient restroom.

During the tour EMP3 and EMP14 confirmed the above findings.

6. Interview with EMP19 on March 2, 2016, at approximately 1:00 PM revealed, "It is not environmental staff responsibility to clean equipment."

7. Interview with EMP14 on March 2, 2016, at approximately 1:45 PM revealed, "My expectation would be that it would be environmental service cleaning it."