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 PRESBYTERIAN SHADYSIDE 200 LOTHROP STREET PITTSBURGH, PA 15213 Sept. 14, 2012
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on review of facility documents and interview of staff (EMP), it was determined that the facility failed to ensure that drugs are administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures.

Findings include:

Review of Job Description, Respiratory Care Intern revealed, "Job Summary: UPMC Shadyside is hiring a limited casual Respiratory Care Intern to help support the day-to-day operations of the SHY-Respiratory Care Service Department for its UPMC Shadyside location. ... Respiratory Care students will develop the ability to gain clinical experience and knowledge prior to the completion of their credentialing in Respiratory Care. The Intern will be under the supervision of the Educational Coordinator, Respiratory Supervisor or their designee and will carry out various responsibilities as outlined below. ...Prepare and administer aerosolized drugs and drug mixtures as prescribed (i.e., bronchodilators, antibiotics, antibacterials, wetting agents, enzymes, steroids, etc.).

1. Interview with EMP1 on August 6, 2012, at approximately 9:30 AM at Shadyside Campus revealed, ..."We have an Educational Coordinator and a Respiratory Supervisor who provides oversight of the students... they [students] have their own assignment..."

2. Interview of EMP2 on August 6, 2012, at 10:30 AM revealed,"...they [students] work independently with indirect supervision...supervisors make up the assignment..."
VIOLATION: RESPIRATORY CARE PERSONNEL POLICIES Tag No: A1161
Based on a review of facility documents and staff interview (EMP) it was determined that the facility failed to ensure that adequate supervision was provided to unlicensed respiratory therapy interns enrolled in the program.

Findings include:

1) Review of "UPMC Shadyside Respiratory Care Services Preceptorship/ Internship Program, August 2012, ... 1. Overview, The Preceptor/Intern Program at UPMC Shadyside is a clinically designed program that provides Interns/Preceptors with the opportunity to continue to develop their patient assessment, management, care and critical thinking skills beyond those that are provided in their structurally designed respiratory Care Program. The additional time that these preceptors spend in a clinical setting provides them with more patient care contact which in turn improves their patient care and respiratory related skills. It assists the intern in making na smooth transition from a student role into a staff therapist role at the time of their graduation. ... V. Preceptorship. A. Upon completion of their Orientation Preceptors/Interns will be assigned to perform Respiratory Care tasks under the indirect supervision of the shift Supervisor and /or Lead Therapist"

2) Interview at Shadyside Campus with EMP2 on August 6, 2012 at 10:30 AM revealed "...students have to fill out a daily journal which is reviewed...they work independently with indirect supervision.. ... ."