HospitalInspections.org

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

The findings were:

482.13 Tag A-0144
The information reviewed during the survey provided evidence the facility failed to ensure observation and the level of observation by a psychiatric care attendant was ordered in four of four applicable medical records (MR) reviewed. The lack of observation allowed one of four MRs reviewed to attempt self-harm by strangulation.

482.13 Tag A-0117
The information reviewed during the survey provided evidence the facility failed to ensure the Medicare Hospital Issued Notification was given/signed for four of six applicable medical records.

A discussion took place with the survey team and the facility's administrative staff (EMP1 and EMP4) regarding the survey team's concerns related to Patient Rights on March 15, 2023, at 1452.

Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.13 (a)(1) Patient Rights: Notice of Rights

Based on review of facility documents, medical records, and staff (EMP) interviews, it was determined the facility failed to ensure the Medicare Hospital Issued Notification was given/signed for four of six applicable medical records (MR8, MR9, MR10, and MR17).

Findings include:

Review on March 15, 2023, of facility policy "Medicare Hospital Issued Notices of Financial Liability and Discharge Appeal," last reviewed October 27, 2022, revealed "...II. Purpose The purpose of this policy is to establish a procedure to inform Medicare beneficiaries of any potential financial liability for non-covered services. ... C. Important Message from Medicare (IMM)... 3. The IMM must be delivered within 2 calendar days of admission, must obtain the signature of the beneficiary or his/her representative, and a copy must be provided to the beneficiary/representative. ..."

Review on March 15, 2023, of MR8, revealed documentation MR8 was eligible to receive the Medicare Notification Message. Further review of MR8 revealed no facility "Important Message from Medicare" notification form.

Interview with EMP3, on March 15, 2023, at 1245, confirmed MR8 was eligible to receive the Medicare Notification Message and MR8 with no facility "Important Message from Medicare" notification form.

Review on March 15, 2023, of MR9, revealed documentation MR9 was eligible to receive the Medicare Notification Message. Further review of MR9 revealed the facility "Important Message from Medicare" notification form with no documentation of signature of patient or representative noted. MR9's "Important Message from Medicare" notification form noted documentation of "verbal due to condition" on the area for signature. MR9's "Important Message from Medicare" notification form with no documentation of witness signature noted.

Interview with EMP3, on March 15, 2023, at 1415, confirmed MR9 was eligible to receive the Medicare Notification Message and MR9's facility "Important Message from Medicare" notification form with no patient/representative or witness signature. EMP3 confirmed MR9's "Important Message from Medicare" notification form noted documentation of "verbal due to condition" on the area for signature, and no documentation of witness signature noted.

Interview with EMP1, on March 15, 2023, at 1420, confirmed MR9's "Important Message from Medicare" notification form noted documentation of "verbal due to condition" on the area for signature, with no witness signature noted. EMP1 confirmed this form should have a witness signature noted.

Review on March 16, 2023, of MR10, revealed documentation MR10 was eligible to receive the Medicare Notification Message. Further review of MR10 revealed the facility's "Important Message from Medicare" notification form with no documentation of a signature of patient or representative, and no documentation of date noted.

Interview with EMP3, on March 16, 2023, at 0920, confirmed MR10 was eligible to receive the Medicare Notification Message and MR10 with no facility "Important Message from Medicare" notification form.

Review on March 16, 2023, of MR17, revealed documentation MR17 was eligible to receive the Medicare Notification Message. Further review of MR17 revealed the facility "Important Message from Medicare" notification form with no documentation of signature of patient or representative, and no date noted.

Interview with EMP6, on March 16, 2023, at 1500, confirmed MR17 was eligible to receive the Medicare Notification Message and MR17's facility "Important Message from Medicare" notification form with no documentation of patient/representative signature or date noted. EMP1 confirmed MR17 refused to sign the form. EMP6 confirmed the form should have had documentation MR17 refused to sign the form and the verbal refusal witness signature on the form with the date noted.

Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to provide a safe environment by failing to ensure observation and the level of observation by a psychiatric care attendant was ordered in seven of seven applicable MRs reviewed (MR1, MR2, MR3, MR4, MR5, MR6, and MR7).

Findings include:

Review on March 15, 2023, of facility policy "Care Attendant Utilization and Observation of Patients," dated May 31, 2022, revealed "I. Policy It is the policy of UPMC to provide for safe and therapeutic observation of patients according to individual patient needs. UPMC will utilize Care Attendants when necessary to provide observation for patients on inpatient nursing units and in emergency departments, in accordance with established standards. ...IV. Definitions: ... Psychiatric Care Attendant: Provides constant observation or special constant observation to assigned suicidal or behavioral health patients under the direction of the RN/LPN, physician, or provider with prescriptive authority. The Psychiatric Care Attendant will have limited direct care responsibilities so that the patient remains in direct eyesight or, as ordered, within arm's reach at all times. As a result, the Psychiatric Care Attendant may not complete other care or ADLs for the patient that would require the Psychiatric Care Attendant to leave the room (such as going into the patient's bathroom) or turn their back on the patient. Staff functioning in the Psychiatric Care Attendant role will be informed of the reason that the patient requires a Psychiatric Care Attendant by the assigned RN/LPN. ... Constant Observation (CO): Whereby the staff continuously observes and may interact individually with the patient while keeping the patient in sight at all times. Additionally, the patient's hands must be visible at all times to the CO staff or Care Attendant. CO must also be completed in the bathroom and when the patient leaves for any medical testing. Patients on CO status may have issues that jeopardize their safety or the safety of others. They may exhibit behaviors or voice thoughts of suicidal, homicidal, or self-injurious intent that require staff or a Care Attendant to be observing them at all times to ensure their safety. Special Constant Observation (SCO): Whereby a staff member or Care Attendant continuously observes the patient within arm's distance. Additionally, the patient's hands must be visible at all times to the SCO staff or Care Attendant. SCO must also be completed in the bathroom and when the patient leaves for any medical testing. Patients on SCO status may have issues that immediately jeopardize their safety or the safety of others. They may exhibit behaviors or voice thoughts of immediate suicidal, homicidal, or self-injurious intent that require staff or a Care Attendant to be observing them at all times to ensure their safety. This level of observation is used when it is necessary to have the staff or Care Attendant close to the patient to prevent the patient from injuring himself or herself. V. Procedure ...Psychiatric Care Attendant 1. The request for a Psychiatric Care Attendant for suicidal or behavioral health patients requires the order of a physician. Nurses may initiate Constant Observation or Special Constant Observation of a patient for the safety of a patient until an order is secured. Discontinuation of a Psychiatric Care Attendant can only be completed with a physician's order. 2. Constant Observation or Special Constant Observation is to be maintained without disruption, and thus, the Psychiatric Care Attendant may have limited duties or care responsibilities, so the patient is in direct eyesight at all times. ...General Guidelines for Care Attendants...1...a. For patients with a positive suicide/homicide screening with or without a civil commitment (201 or above in PA) - a Psychiatric Care Attendant is required and ordered by the provider. ... "

Review on March 15, 2023, revealed MR1 was receiving treatment in the Emergency Department (ED) on March 9, 2023, for a worsening depression and SI. Documentation revealed MR1 screened positive for suicide risk. Nursing document revealed MR1 was placed on 1:1 observation. MR1 did not have a provider order for a psychiatric care attendant and therefore the level of observation was not specified. Further review of MR1 revealed at approximately 1945, staff found MR1 lying on the floor with the elastic waist band of the paper scrubs tied around his/her neck.

Interview with EMP2 on March 15, 2023, at 0900 confirmed MR1 had nursing documentation of 1:1 observation but did not have a provider order for a psychiatric care attendant.

Interview with EMP5 on March 15, 2023, at 0936 confirmed MR1 attempted self-harm by strangulation on March 9, 2023, at 1945.

Review on March 15, 2023, revealed MR2 was on an involuntary commitment for paranoia and a recent suicide attempt from March 2, 2023, at 1820 until transfer to an outside facility on March 3, 2023, at 1343. Documentation revealed MR2 screened positive for suicide risk. Nursing documentation revealed MR2 was on 1:1 observation. MR2 did not have a provider order for a psychiatric care attendant and therefore the level of observation was not specified.

Interview with EMP2 on Marcy 15, 2023, at 1100 confirmed MR2 had nursing documentation of 1:1 observation but did not have a provider order for a psychiatric care attendant.

Review on March 15, 2023, revealed MR3 was on a voluntary commitment in the ED on March 9, 2023. Documentation revealed MR3 screened positive for suicide risk. Nursing documentation revealed MR3 was on 1:1 observation. MR3 did not have a provider order for a psychiatric care attendant and therefore the level of observation was not specified.

Interview with EMP2 on Marcy 15, 2023, at 1330 confirmed MR3 had nursing documentation of 1:1 observation but did not have a provider order for a psychiatric care attendant.

Review on March 15, 2023, revealed MR4 was a mental health patient in the ED on March 9, 2023. Documentation revealed MR4 screened positive for suicide risk. Nursing documentation revealed MR4 was on 1:1 observation. MR4 did not have a provider order for a psychiatric care attendant and therefore the level of observation was not specified.

Interview with EMP2 on Marcy 15, 2023, at 1345 confirmed MR4 had nursing documentation of 1:1 observation but did not have a provider order for a psychiatric care attendant.

Review on March 15, 2023, of MR5 revealed documentation MR5 was admitted to the ED on March 9, 2023, at 2203, on a voluntary commitment for suicidal ideation. Documentation noted MR5 screened positive for suicide risk. Nursing documentation noted MR5 was on 1:1 observation. MR5 did not have a provider order for a psychiatric care attendant until March 13, 2023, and the level of observation (within arms' distance) was not specified until March 13, 2023.

Interview with EMP3, on March 15, 2023, at 1000 confirmed documentation MR5 was admitted to the ED on March 9, 2023, at 2203 on a voluntary commitment for suicidal ideation. EMP3 confirmed documentation noted MR5 screened positive for suicide risk. Nursing documentation noted MR5 was on 1:1 observation. MR5 did not have a provider order for a psychiatric care attendant until March 13, 2023, and the level of observation (within arms' distance) was not specified until March 13, 2023.

Review on March 15, 2023, of MR6, revealed documentation MR6 was admitted to the ED on March 11, 2023, at 1150 on a voluntary commitment for homicidal ideation (commitment changed to involuntary on March 13, 2023). Documentation noted MR6 screened positive for suicide risk. Nursing documentation revealed MR6 was on 1:1 observation. MR6 did not have a provider order for a psychiatric care attendant until March13, 2023, and the level of observation (within arms' distance) was not specified until March 13, 2023.

Interview with EMP3, on March 15, 2023, at 1045, confirmed documentation MR6 was admitted to the ED on March 11, 2023, at 1150 for homicidal ideation. EMP3 confirmed documentation noted MR6 screened positive for suicide risk. Nursing documentation noted MR6 was on 1:1 observation. MR6 did not have a provider order for a psychiatric care attendant until March 13, 2023, and the level of observation (within arms' distance) was not specified until March 13, 2023.

Review on March 15, 2023, of MR7, revealed documentation MR7 was admitted to the ED on March 14, 2023, at 2222 for suicidal ideation. Documentation revealed MR7 screened positive for suicide risk. Nursing documentation revealed MR7 was on 1:1 observation. MR7 did not have a provider order for a psychiatric care attendant and therefore the level of observation was not specified.

Interview with EMP3, on March 15, 2023, at 1115 confirmed documentation MR7 was admitted to the ED on March 14, 2023, at 2222 for suicidal ideation. EMP3 confirmed MR7 had nursing documentation of 1:1 observation but did not have a provider order for a psychiatric care attendant.

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

The findings were:

482.23(b) Tag A-0392 Nursing Services: Staffing and Delivery of Care
The information reviewed during the survey provided evidence the facility failed to ensure adequate staff were available to provide 1:1 observation of psychiatric patients in the emergency department (ED) in one of four applicable MRs reviewed and failed to provide adequate staff to ensure 1:1 patient observations per approved facility policy for 13 of 18 days.

482.23(b)(5) Tag A-0397 Nursing Services: Patient Care Assignments
The information reviewed during the survey provided evidence the facility failed to ensure staff had the required training/certification to provide patient observation in two of nine applicable personnel files (PF) reviewed.

482.23(b)(6) Tag A-0398 Nursing Services: Supervision of Contract Staff
The information reviewed during the survey provided evidence the facility failed to ensure staff followed approved policy for documentation of the reason for observation in four of five MRs reviewed; failed to ensure documentation of observation was completed in two of four MRs reviewed, and; failed to provide the observation level ordered in two of two MRs reviewed.

A discussion took place with the survey team and the facility's administrative staff (EMP1 and EMP4) regarding the survey team's concerns related to Nursing Services on March 15, 2023, at 1452.

Cross reference
482.23(b) Nursing Services: Staffing and Delivery of Care
482.23(b)(5) Nursing Services: Patient Care Assignments
482.23(b)(6) Nursing Services: Supervision of Contract Staff

Based on review of facility documents and medical record (MR), and staff interview (EMP), it was determined the facility failed to provide adequate staff to ensure 1:1 observation of a suicidal psychiatric patient (MR1) and failed to provide adequate staff to ensure 1:1 patient observations for 13 of 18 days between February 26, 2023 - March 10, 2023.

Findings include:

Review on March 15, 2023, of facility policy "Care Attendant Utilization and Observation of Patients," dated May 31, 2022, revealed "I. Policy It is the policy of UPMC to provide for safe and therapeutic observation of patients according to individual patient needs. UPMC will utilize Care Attendants when necessary to provide observation for patients on inpatient nursing units and in emergency departments, in accordance with established standards. ...IV. Definitions: ... Psychiatric Care Attendant: Provides constant observation or special constant observation to assigned suicidal or behavioral health patients under the direction of the RN/LPN, physician, or provider with prescriptive authority. The Psychiatric Care Attendant will have limited direct care responsibilities so that the patient remains in direct eyesight or, as ordered, within arm's reach at all times. As a result, the Psychiatric Care Attendant may not complete other care or ADLs for the patient that would require the Psychiatric Care Attendant to leave the room (such as going into the patient's bathroom) or turn their back on the patient. ... "

1. Review on March 15, 2023, revealed MR1 was brought to the emergency department (ED) on March 9, 2023, via ambulance for worsening depression, suicidal ideation (SI), and a history of seizures and self-harm. MR1 was assessed and found to have a positive suicidal risk score. Physician documentation revealed MR1 was moved to the mental health area of the ED and placed on 1:1 observation. Further review of documentation revealed, at approximately 1945, staff found MR1 lying on the floor with the elastic waist band of the paper scrubs tied around his/her neck.

Interview with EMP5 on March 15, 2023, at 0936 confirmed the above documentation and MR1 was on 1:1 observation in the preferred pod for behavioral health patients. EMP5 further revealed, prior to 1900 on March 13, 2023, PF2 was assigned to provide 1:1 observation of MR1 in room 35. PF2 left the area at 1859 and handed observation of MR1 over to PF4 because PF2's relief was not going to be available until approximately 1915. At the time of handoff, PF4 was also providing 1:1 observation for room 36 and a hallway bed in the area. At 1915 PF3 arrived and assumed 1:1 observation of MR1 and was also assigned responsibility for observation of one of two new patient admissions received at the change of shifts at 1900. PF3 was observing both MR1 and one of the new admissions from the hall outside the side-by-side rooms. Due to the new patient admission's escalating behaviors, PF3 left the hall and entered that patient's room, leaving MR1 unobserved. At approximately 1945, PF4 walked by the video monitoring screen and observed MR1 on the floor. PF4 notified PF1 who found MR1 on the floor with the elastic waist band of the paper scrubs tied around his/her neck.

Review on March 15, 2023, of the ED nursing staff schedules for February 26, 2023 - March 15, 2023, revealed no concerns.

Interview with EMP5, on March 15, 2023, at 1500, confirmed the ED is staffed according to the staffing plan, but additional staff may be necessary to provide 1:1 patient observation. Staff members are assigned as needed and addition staff may be pulled from staff trained for 1:1 patient observation from other units. EMP5 confirmed staff are utilized from numerous areas in the facility, i.e., nursing units.

2. Review on March 15, 2023, of the ED nursing staff assignments for February 26, 2023 - March 10, 2023, revealed 1:1 staff member coverage not adequate at times during the 24-hour period. Documentation on February 26, 2023, noted one 1:1 staff member assigned to observe two patients 1900 - 2300 and 2300 - 0300. Documentation on February 27, 2023, noted two 1:1 staff members were each assigned to observe two patients between 1900 - 2300, and one 1:1 staff member was assigned to observe three patients between 2300 - 0300 and 0300 - 0700. Documentation on February 28, 2023, noted one 1:1 staff member was assigned to observe three patients between 0700 - 1100, and one 1:1 staff member was assigned to observe two patients between 1500 - 1900 and 1900 - 2300. Documentation on March 1, 2023, noted one 1:1 staff member assigned to observe two patients between 1500 - 1900, two 1:1 staff members each assigned to observe two patients between 1900 - 2300, and three 1:1 staff members assigned to observe two patients each between 2300 - 0300 and 0300 -0700. Documentation on March 2, 2023, noted three 1:1 staff members assigned to observe two patients each between 0700 - 1100, one 1:1 staff member assigned to observe two patients between 1500 - 1900, three 1:1 staff members assigned two patients each between 1900 - 2300, and two 1:1 staff members each assigned to observe two patients between 2300 - 0300 and 0300 - 0700. Documentation on March 3, 2023, noted one 1:1 staff member assigned to observe two patients and one 1:1 staff member assigned to observe three patients between 0700 - 1100, three 1:1 staff members assigned to two patients each between 1100 - 1500, one 1:1 staff member assigned to observe three patients and one 1:1 staff member assigned to observe two patients between 1500 - 1900, two 1:1 staff members assigned to observe two patients each between 1900 - 2300, and one 1:1 staff member assigned to observe two patients between 2300 - 0300 and 0300 - 0700. Documentation on March 4, 2023, noted one 1:1 staff member assigned to observe two patients between 0700 - 1100, and one 1:1 staff member assigned to observe two patients between 2300 - 0300 and 0300 - 0700. Documentation on March 5, 2023, noted one 1:1 staff member assigned to observe two patients between 1500 - 1900, 1900 - 2300, and 2300 - 0300. Documentation on March 6, 2023, noted one 1:1 staff member assigned to observe two patients between 0700 - 1100 and 1100 - 1500, one 1:1 staff member assigned to observe three patients between 1900 - 2300, and one 1:1 staff member assigned to observe two patients between 2300 - 0300. Documentation on March 7, 2023, noted one 1:1 staff member assigned to observe two patients between 1100 - 1500, 2300 - 0300, and 0300 - 0700. Documentation on March 8, 2023, noted one 1:1 staff member assigned to observe two patients between 0700 - 1100 and 1100 - 1500 and two 1:1 staff members assigned to observe two patient each between 2300 - 0300 and 0300 - 0700. Documentation on March 9, 2023, noted one 1:1 staff member assigned to observe two patients between 0700 - 1100, 1100 - 1500, 1500 - 1900 and 0300 - 0700 and two 1:1 staff members assigned to observe two patients each between 1900 - 2300. Documentation on March 10, 2023, noted one 1:1 staff member assigned to observe two patients between 0700 - 1100 and 1100 - 1500.

Interview with EMP5, on March 15, 2023, at 1510 confirmed the 1:1 staff member coverage for February 26, 2023 - March 10, 2023, was not adequate per facility policy.

Review on March 15, 2023, of the ED nursing staff assignments for March 11, 202 through March 14, 2023, revealed 1:1 staff member assignments appropriate.

Based on observation, review of facility documentation and staff (EMP) interview, it was determined the facility failed to ensure staff had the required training/certification to provide patient observation in two of nine applicable personnel files (PF) reviewed (PF3 and PF13).

Findings include:

Review on March 16, 2023, of facility policy "Care Attendant Utilization and Observation of Patients dated May 31, 2022, revealed "I. Policy It is the policy of UPMC to provide for safe and therapeutic observation of patients according to individual patient needs. UPMC will utilize Care Attendants when necessary to provide observation for patients on inpatient nursing units and in emergency departments, in accordance with established standards. ...General Guidelines for Care Attendants...4. Care Attendant requirements: a. Must meet the job descriptions and adhere to the UPMC Care Attendant job description. ..."

Review on March 16, 2023, of the facility job description for "Safety Sitter," no date provided, revealed "...Education and Knowledge Requirements...BLS-Basic Life Support Certification required..."

Interview with EMP5 on March 15, 2023, at 0936 revealed the facility uses the terms safety sitters and care attendants interchangeably and therefore utilizes safety sitters/care attendants to provide observation of psychiatric patients.

Review on March 16, 2023, revealed the job description for PF3's primary employment role did not require basic life support (BLS) certification. There was no BLS certification in PF3. Further review revealed PF3 had performed the duties of a psychiatric care attendant for MR1 on March 13, 2023.

Interview with EMP8 on March 16, 2023, at 1020 confirmed PF3 had no BLS certification on file.

Interview with EMP5 on March 15, 2023, at approximately 0945, confirmed PF3 had performed 1:1 observation as a psychiatric care attendant for MR1 on March 13, 2023.

Review on March 16, 2023, revealed the job description for PF13's primary employment role did not require BLS certification. There was no BLS certification in PF13. Observation on March 16, 2023, at 0925 revealed PF13 was performing the duties of a psychiatric care attendant in the ED behavioral health pod on March 16, 2023.

Interview with EMP5 on March 16, 2023, at the time of the observation confirmed PF13 was performing the duties of a psychiatric care attendant for one of three mental health patients in the ED behavioral health pod.

Based on review of facility policy, documentation, and medical records (MR), observation, and staff (EMP) interview it was determined the facility failed to ensure staff followed approved policy for the documentation of the reason for observation in four of five MRs reviewed (MR3, MR4, MR6, and MR7); failed to ensure documentation of observation was completed in two of four MRs reviewed (MR1 and MR2), and; failed to provide the level of observation ordered in two of two MRs reviewed (MR5 and MR6).

Findings include:

1. Review on March 15, 2023, of facility policy "Care Attendant Utilization and Observation of Patients," dated May 31, 2022, revealed "...IV. Definitions: ... Psychiatric Care Attendant: ... staff functioning in the Psychiatric Care Attendant role will be informed of the reason that the patient requires a Psychiatric Care Attendant by the assigned RN/LPN. ..."

Review on March 15, 2023, of the facility form " Constant Observation Flowsheet," dated March 1, 2018, revealed "Directions: 1. RN to complete reason for constant observation at the initiation of form every 24 hours. ...Reason: Suicide Risk, Risk to harm self or others (Behavioral Health Reason), Fall Risk, Elopement Risk, Risk to discontinue therapeutic interventions ... "

Review on March 15, 2023, revealed MR3 was on a voluntary commitment in the ED on March 9, 2023. Review of the "Constant Observation Flowsheet" for 0700 on March 9 until 0700 on March 10, 2023, revealed the reason for observation was not indicated and the RN signature line was blank.

Interview with EMP2 on March 15, 2023, at 1330 confirmed the observation flow sheet for MR3 for 0700 on March 9 until 0700 on March 10, 2023, lacked the reason for observation and the RN signature.

Review on March 15, 2023, revealed MR4 was on constant observation from 1100 on March 9 until 1426 on March 13, 2023. Review of observation flow sheets for March 10, 11, 12, and March 13, 2023, revealed the sheets lacked the reason for observation and RN signatures.

Interview with EMP2 on March 15, 2023, at 1345 confirmed the observation flow sheets for MR4 for March 10, 11, 12, and March 13, 2023, lacked the reason for observation and RN signatures.

Review on March 16, 2023, revealed MR6 was on a voluntary commitment in the ED on March 11, 2023, at 1150. Review of the "Constant Observation Flowsheet" for 0700 on March 15, 2023, until 0700 on March 16, 2023, revealed the reason for observation was not indicated.

Interview with EMP5 on March 16, 2023, at 1145 confirmed the observation flow sheet for MR6 for 0700 on March 15, 2023, until 0700 on March 16, 2023, lacked the reason for observation. EMP5 confirmed the RN is to complete the reason for constant observation at the time the form is initiated.

Review on March 16, 2023, revealed MR7 was on an involuntary commitment in the ED on March 14, 2023, at 2222. Review of the "Constant Observation Flowsheet" for 0700 on March 15, 2023, until 0700 on March 16, 2023, revealed the reason for observation was not indicated.

Interview with EMP5 on March 16, 2023, at 1150, confirmed the observation flow sheet for MR7 for 0700 on March 15, 2023, until 0700 on March 16, 2023, lacked the reason for observation. EMP5 confirmed the RN is to complete the reason for constant observation at the time the form is initiated.

2. Review on March 15, 2023, of the facility form "Constant Observation Flowsheet," dated March 1, 2018, revealed "Directions: ...2. Constant Observer to document Q15 minute observations..."

Review on March 15, 2023, of MR1 revealed nursing notes documented MR1 was under 1:1 observation during an ED visit on March 9 at 1550 until 0340 on March 10, 2023. Further review of MR1 revealed there was no documentation of every 15-minute observations.

Interview with EMP2 on March 15, 2023, at 0900 confirmed there was no documentation of every 15-minute checks during MR1's ED visit of March 9 through March 10, 2023.

Interview with EMP1 on March 15, 2023, at approximately 1400, confirmed the documentation of 15-minute checks for MR1's ED visit on March 9, 2023, could not be located.

Review on March 15, 2023, of MR2 revealed a "Constant Observation Flowsheet" was signed by the RN at 2108 on March 2, 2023. Review of the documentation of every 15-minute observations revealed documentation did not begin until 2200 on March 2, 2023.

Interview with EMP2 on March 15, 2023, at 1030 confirmed documentation in MR2 of the 15-minute observations did not begin until 2200 on March 2, 2023.

3. Review on March 15, 2023, of facility policy "Care Attendant Utilization and Observation of Patients," dated May 31, 2022, revealed "I. Policy It is the policy of UPMC to provide for safe and therapeutic observation of patients according to individual patient needs. UPMC will utilize Care Attendants when necessary to provide observation for patients on inpatient nursing units and in emergency departments, in accordance with established standards. ...IV. Definitions: ... Special Constant Observation (SCO): Whereby a staff member or Care Attendant continuously observes the patient within arm's distance. Additionally, the patient's hands must be visible at all times to the SCO staff or Care Attendant. SCO must also be completed in the bathroom and when the patient leaves for any medical testing. Patients on SCO status may have issues that immediately jeopardize their safety or the safety of others. They may exhibit behaviors or voice thoughts of immediate suicidal, homicidal, or self-injurious intent that require staff or a Care Attendant to be observing them at all times to ensure their safety. This level of observation is used when it is necessary to have the staff or Care Attendant close to the patient to prevent the patient from injuring himself or herself. V. Procedure ...Psychiatric Care Attendant 1. The request for a Psychiatric Care Attendant for suicidal or behavioral health patients requires the order of a physician. ..."

Observation on March 15, 2023, at 0920, revealed MR5 on constant observation. Observation revealed a 1:1 staff member sitting in the room doorway, observing MR5.

Review on March 15, 2023, of MR5, revealed nursing notes documented MR5 was on constant observation during an ED visit on March 9 at 2300, through March 15 at 0915. Further review revealed an order March 13, 2023, at 1059, for SCO (within arms' distance).

Interview with EMP5, on March 15, 2023, at 1015, confirmed the 1:1 staff member was observing MR5 from the room doorway and was not within arms' distance.

Observation on March 15, 2023, at 0920, revealed MR6 on constant observation. Observation revealed a 1:1 staff member sitting in the room doorway, observing MR6.

Review on March 15, 2023, of MR6, revealed nursing notes documented MR6 was on constant observation during an ED visit on March 11 at 1200, through March 15 at 0915. Further review revealed an order March 13, 2023, at 1058, for SCO (within arms' distance).

Interview with EMP5, on March 15, 2023, at 1050, confirmed the 1:1 staff member was observing MR6 from the room doorway and was not within arms' distance.