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UPMC PRESBYTERIAN SHADYSIDE 200 LOTHROP STREET PITTSBURGH, PA 15213 Sept. 14, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
During a review of facility policies and procedures and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide patients the notice of patient rights for 13 of 31 medical records reviewed (MR3, MR6, MR11, MR13, MR14, MR18, MR19, MR20, MR21, MR22, MR23, MR24, and MR25).

Findings include:

Review of Policy "Patients' Notice and Bill of Rights and Responsibilities" dated December 4, 2015, revealed, "III. Purpose The Patients' Notice and Bill of Rights and Patient Responsibilities is made available to patients, their family members and representatives via patient information materials and postings. This information shall be posted in Registration areas and within each service location. Staff is responsible to assure that this information is also made available to patients, families, and their representatives upon request. ... IV. Patients' Notice And Bill Of Rights ... As an Individual receiving service at UPMC you have a right to be informed of your rights at the earliest possible moment in the course of your care, treatment or service and to exercise your rights as our partner in care."
Review of Policy "Patient Complaint Management and Grievance Process" dated October 22, 2015, revealed, "...A. Notice... 2. Upon being informed of the content of the Patient Rights and Patient responsibilities, which will be included in the patient's admissions information and posted in outpatient and registration areas ..."
1. Review of the admission assessments for MR3, MR6, MR11, MR13, MR14, MR18, MR19, MR20, MR21, MR22, MR23, MR24, and MR25 on September 14, 2016, revealed no documentation to indicate the patients were provided a copy of a patient handbook which included the Patient Bill of Rights.
2. Interview with EMP5 on September 14, 2016, at approximately 12:20 PM confirmed the above findings and revealed "We do not routinely give them [copy of patient rights] out. If a patient asks for it we hand them one, only on request."

3. Interview with EMP6 on September 14, 2016, at approximately 12:30 PM confirmed the above findings and revealed "It is the units responsibility to given them [the patients] a packet."

4. Interview with EMP2 on September 14, 2016, at approximately 1:00 PM confirmed the above findings and revealed "We are looking at this, everyone seems to have a different answer."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy and procedures, medical records (MR), and staff interview (EMP), it was determined the facility failed to implement and adhere to safety measures during the admission assessment for 11 of 30 medical records reviewed (MR4, MR6, MR9, MR12, MR15, MR18, MR23, MR24, MR26, MR29, MR31).

Findings include:

Review of facility policy and procedure "Patient Assessment/Reassessment" dated October 22, 2015, revealed "B. Nursing (Medical-Surgical/Psychiatry) ... 4. Elements to be assessed at the time of the admission nursing history and physical assessment include a complete allergy and reaction history"

1. Review of MR4 revealed the patient was admitted on [DATE]. Further review revealed the last time the allergy and reaction history was updated was June 23, 2016.

2. Review of MR6 revealed the patient was admitted on [DATE]. Further review revealed the last time the allergy and reaction history was updated was December 22, 2015.

3. Review of MR9 revealed the patient was admitted on [DATE]. Further review revealed the last time the allergy and reaction history was updated was April 3, 2016.

4. Review of MR12 revealed the patient was admitted on [DATE]. Further review revealed the last time the allergy and reaction history was updated was March 27, 2016.

5. Review of MR15 revealed the patient was admitted on [DATE]. Further review revealed the last time the allergy and reaction history was updated was March 24, 2016.

6. Review of MR18 revealed the patient was admitted on [DATE]. Further review revealed the last time the allergy and reaction history was updated was July 1, 2015.

7. Review of MR23 revealed the patient was admitted on [DATE]. Further review revealed the last time the allergy and reaction history was updated was February 4, 2008.

8. Review of MR24 revealed the patient was admitted on [DATE]. Further review revealed the last time the allergy and reaction history was updated was February 19, 2016.

9. Review of MR26 revealed the patient was admitted on [DATE]. Further review revealed the last time the allergy and reaction history was updated was July 21, 2016.

10. Review of MR29 revealed the patient was admitted on [DATE]. Further review revealed the last time the allergy and reaction history was updated was July 27, 2016.

11. Review of MR31 revealed the patient was admitted on [DATE]. Further review revealed the last time the allergy and reaction history was updated was August 1, 2015.

Interview with EMP1 on September 14, 2016, at approximately 1:15 PM confirmed the above findings and revealed "You are correct."