The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

UPMC ALTOONA 620 HOWARD AVENUE ALTOONA, PA 16601 Sept. 2, 2016
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
Based on a review of facility documents and staff interviews (EMP), it was determined that UPMC Altoona failed to follow their adopted policies and procedures to refer a patient grievance to their Customer Service Department for immediate investigation in one of one grievances reviewed.

Findings include:

UPMC Altoona, Standard of Practice, Subject: Patient/Visitor Complaint/Grievance Investigation/Documentation, ... Reviewed: 8/31/15. "... Complaints/grievances are lodged in a variety of ways: Calls from hospital personnel on behalf of patients, referrals from physicians/community/regulatory agencies, direct contact from patients or family members, patient surveys and correspondence. For the purpose of the Standard of Practice, a "Grievance" is defined as an injury, injustice, or wrong that gives grounds for a complaint. A patient issue is not a grievance if the patient issue can be resolved promptly on the spot by staff present. All staff members are expected to accept concerns/grievances on behalf of patients/families and attempt to achieve an amicable resolution. It the staff member or immediate supervisor is unable to immediately resolve the complaint's concern, the grievance will be documented and referred to the Customer Service Department ... All grievances can be forwarded to ... Complete documentation of complaint will be made immediately by the Customer Relations Associate or the Executive Director of Mission and Customer Service into the grievance data base ... The complainant will be assured that his grievance will be immediately investigated. In all grievance concerns, an acknowledgment letter will be sent within seven working days. If the situation is not able to be resolved within the seven days, then the acknowledgment letter will advise the complainant that a final written resolution letter outlining the steps taken to resolve the issue will be sent within thirty days ... ."

1. An interview was conducted on August 19, 2016, at approximately 10:28 AM, with EMP5 ... "The patient stated that we were holding them against their will. They felt that their rights were violated. I explained that they were very agitated, disoriented and had kicked the sitter in the chest ... the patient disagreed with every thing and did not want to listen to anything I was saying. I tried to reason with the patient ... they wanted to sign out AMA ... We did not have any Incident Reports related to this complaint. ... I did not report this in Risk Master ... The staff member who got kicked should have filled out an Incident Report. I did not call Customer Service to let them know about the event. The patient was not satisfied with the conversation that we had. You could not reason with the patient, they argued with everything I had to say."

2. An interview was conducted with EMP6 on August 19, 2016, at approximately 10:45 AM. "EMP5 should have called EMP2 or EMP7 if the patient was not satisfied. That is the process and they should have referred the patient's concerns on to Customer Service."

3. An interview was conducted with EMP7 on August 19, 2016 at approximately 1:50 PM. "EMP5 never report this to me, I did not know about this until the patient filed a complaint in August. I spoke with EMP2 about this and reviewed things that needed to be report to us. This should have been reported to Customer Service."
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on staff interviews (EMP) and observation it was determined that UPMC Altoona failed to segregate clean and soiled textiles.

Findings include

UPMC Policy: HS-NA0417 ... "Subject: Linen Management Guidelines, July 1, 2016. I. Policy It is the policy of UPMC to establish appropriate linen utilization and management strategies ... E. Clean Linen: Clean linen shall be stored and covered on linen carts in the Linen Room. The door shall be kept closed ... F. Soiled Linen: Soiled linen should be handled as little as possible and with minimal agitation to prevent microbial contamination of the air and persons handling the linen ... II. Procedures: A. Delivery: Clean linen is delivered to UPMC hospitals and to individual units/departments in a manner which minimizes microbial contamination from surface or airborne deposition ... ."

Altoona Regional Health System, Infection Control Policy, Linen Room. "1. Infection Control Policy: To insure safe storage of clean and soiled linen, proper handling of soiled and contaminated linen, safe transport, protection of the Linen Room staff from work associated infection, adequate sanitizing of linens, proper covering of clean linens and sanitary delivery vehicles ... ."

1. During a tour of the facility on September 1, 2016, at approximately 2:20 PM, it was observed in Room N-G12 that four storage bins of clean textiles were not covered to prevent dust and soil from nearby soiled items.

2. An interview was conducted with EMP 11 on September 2, 20-16 at approximately 1:00 PM. "I went and looked at the bins and they should have a cover on them.

3. During a tour on September 1, 2016, it was observed that the door to Room 273, which is the primary Soiled Linen Holding Room, was held open with a weight, and that the door to Room 274, which is a Soiled Overflow room, was not closed.

4. The above findings were confirmed by EMP6