HospitalInspections.org

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that UPMC Pinnacle failed to ensure the protection and promotion of the rights of patients by failing to provide care in a safe setting.

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this Condition.

Cross reference:
482.13(c)(2) Patient Rights: The patient has the right to receive care in a safe setting.

Based on a review of facility documents and staff interview (EMP), it was determined that UPMC Pinnacle Hospitals failed to maintain a safe environment for patients by failing to supervise a patient as per the Physician Order, resulting in the patient being able to lock themselves into the bathroom on two occasions and removing the mirror off the wall and using pieces of the mirror as a weapon.


Findings include:

The review of facility policy revealed "Suicide Precautions for Inpatient Hospital Admissions. 1. Policy: Patients determined to be high risk for suicide will be placed on suicide precautions and an order for such will be obtained ... IV 1:1 Direct Continuous Observation - Staff continuously observes the patient while staying within 5 feet of the patient at all times. 1:1 direct continuous observations must be provided in the bathroom, shower and at any time the patient is off the Unit for testing or other procedures. Continuous observation must be provided to allow staff to immediately intervene should the patient attempt suicide ... ."


MR1 Nursing Note ... December 15, 2021 at 2:50 PM "... Patient was using the phone ... with this RN at the bedside. ... This RN informed the patient that they needed to return the phone if they were going to speak that way. While refusing to return the phone, ... contacted Telecom to turn off the service for the phone the patient was using. When the service was shut off, the patient opened the door and threw the phone at three nurses out at the Main desk. Patient then went into the bathroom, turned on the shower and stood under the running water wearing paper scrubs. Patient then walked out to the hallway, soaking wet, and then back into the room. Patient went back into the bathroom, locked self in there, and removed the mirror off the wall and broke the glass. ... Once Security was present in the room, ... called a Code Green. ..."

"... Nursing Note ... December 15, 2021 at 3:36 PM ... Security already present and attempting to unlock bathroom door where the patient had locked self in after kicking Security. There was a loud crashing noise from in the bathroom. Security then was able to get the door open to the bathroom. Patient was found holding a broken mirror that they had pulled off of the wall. As Security and nurse entered the room patient reached down and grabbed a large piece of broken glass from the floor and attempted to stab at Security and nurse. Security and nurse then attempted to get the piece of glass from patient while patient attempted to stab at own neck. ... but the glass did cut the palm of patient's right hand from where they had been griping the glass. ... ."



Interview conducted on December 20, 2021, with EMP1 confirmed that the patient was ordered to be on 1:1 for suicide precautions. While the staff member was blocking exit to the room, the patient was able to enter the bathroom before staff member could get around the bed. The patient was able to lock self in the bathroom on two occasions. The patient was also able to remove a mirror from the bathroom wall, break the mirror and use the pieces as a weapon.