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Based on a review of facility policy, medical records (MR) and staff interview (EMP), it was determined that the facility failed to monitor the condition of restrained patients in one medical record reviewed (MR10).

Findings include:

A review of Policy HS-NA0416*, on April 22, 2022, Restraint and Seclusion, (Last Revised March 30, 2022) states in Section VIII Use of Restraint for Non Violent/ Non Self Destructive Behavior, D. Ongoing Patient Assessment and Care Interventions #4, "The continued need for the use of restraint Non Violent/Non Self Destructive behavior will be reassessed and documented in the medical record at the following frequencies or more often as the patient condition requires. a. Non Violent/Non Self Destructive behavior- every 2 hours."

A review of MR10 on April 22, 2022 (Emergency Department: 1/3/2022; Admission Date: 1/4/2022, Discharge Date: 01/20/2022) revealed the following:

Evidence of the two-hour nursing assessment for nonviolent non self-destructive restraint use was absent in the record on the following dates and times:
1) 01/03/2022: Missing two-hour nursing assessment at 06:00am, 12 noon, and 02:00pm 01/06/2022: Missing two-hour nursing assessment at 08:00pm and 10:00pm.

2) 01/08/2022: Missing two-hour nursing assessment at 08:00am, 10:00am, 12 noon, 02:00pm, 04:00pm, and 06:00pm.

3) 01/15/2022: Missing two-hour nursing assessment at 04:00pm.

The above findings were confirmed by EMP3 at 12:27pm on April 22, 2022.

Based on a review of facility policy and facility documents (OTH), and staff interviews (EMP), it was determined that the facility failed to address four of 10 components of the COVID-19 vaccination mandate.

Findings include:

1. On April 21, 2022, a review of facility policy, HS-IC0623: COVID-19 Vaccination Program (Last Reviewed, March 21, 2022), failed to address the following requirements:
a. All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and
b. A statement by the authenticating practitioner recommending that the staff member be exempted from the hospital's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications.

2. A review of the UPMC Vaccination Exemption Committee protocol (undated), on April 21, 2022, reveals the following:
a. Covid Vaccine Medical and Religious Exemption Process: #4 For permanent medical exemptions, documentation should be provided (unless documented reaction or vaccine adverse event is already on file in an existing UPMC medical record) and must be signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and contain a statement advising against COVID-19 vaccination.

3. On April 22, 2022, EMP2 confirmed that two components of the COVID-19 vaccination mandate were not included in the facility policy.

4. A review of two filed medical exemptions, OTH14 and OTH15, determined the the exemptions failed to specify which of the COVID-19 authorized vaccines are clinically contraindicated.

5. On April 21, 2022, a review of facility policy, HS-IC0623: COVID-19 Vaccination Program (Last Reviewed, March 21, 2022), Section D. 1 and 2 as follows: " 1. Students: Each academic institution shall be responsible for maintaining and managing student vaccination records and approved medical and religious exemptions with this policy. Students engaged in clinical rotation or otherwise providing services at a UPMC Covered Facility in conjunction with an educational program shall submit proof of vaccination or exemption request directly to their academic program. 2. Vendors: Each vendor shall be responsible for compiling, maintaining, and managing proof of vaccination records and approved medical or religious exemptions for its own employees, sub-contractors, or other individuals covered by this policy to ensure compliance with the requirements set forth herein. Upon request, vendors must provide to UPMC entities proof of vaccination or approved medical or religious exemption of any individuals covered by this section.

6. Further review of the policy revealed that the policy failed to specifically address and define the requirement for students and those who provide other services for the hospital and/or its patients under contract or by other arrangement.

On May 3, 2022, at 11:15am, EMP4 confirmed the above findings.