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 Jan. 6, 2017
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to comply with their patient safety plan for disclosure of serious events to patient/significant other for three of 10 medical records reviewed (MR1, MR19 and MR20).
Review of facility Patient Safety Plan, August 2015, revealed, " ... E. Identification, reporting and disclosure of Healthcare-Associated Infections (HAI) ... 3. Disclosure of HAI a. HAI will be considered serious events under Mcare. B. Letters of disclosure will be sent to the patient/significant other within 7 days of confirmation of the infection."

1. Review of MR1 revealed a health-care associated lung infection date of October 14, 2016. Review of facility documents revealed no letter of disclosure was sent to the patient or significant other.

2. Further review of MR1 revealed a health-care associated bloodstream infection date of October 9, 2016. Review of facility documents revealed no disclosure was sent to the patient or significant other.

3. Review of MR19 revealed a health-care associated lung infection date of October 17, 2016. Review of facility documents revealed no disclosure was sent to the patient or significant other.

4. Review of MR20 revealed a health-care associated bloodstream infection date of October 13, 2016. Review of facility documents revealed no disclosure was sent to the patient or significant other.

5. Interview with EMP1, on January 5, 2016 at approximately 11:00 am, confirmed the above findings and revealed, "We didn't send the letters, it was a clerical error."