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. 11, 2019
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on a review of facility policy, a tour of the facility and staff interviews (EMP), it was determined that the facility failed to post conspicuously in treatment areas a sign specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor.

Findings include:

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated October 29, 2018, revealed, " ... V. PROCEDURE ... 10. The facility shall post clear and visible signage that identifies the rights of the individual under EMTALA with respect to examination and treatment for Emergency Conditions and indicates the hospitals participation in the Medicare and Medicaid programs."

A tour of the Diagnostic Evaluation Center (DEC, a dedicated emergency department) on January 8, 2019, at approximately 12:00 PM, revealed no visible signage reflecting the rights of the individual under EMTALA with respect to examination and treatment for emergency conditions in any of the treatment rooms or triage area.

An interview with EMP7 at the time of the tour confirmed the above findings.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on a review of facility policy and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to comply in the case of the hospital as defined in 489.24(b).


Findings include:

A review of facility policy and procedure "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated October 29, 2018, revealed, "Definitions ... 2. Emergency Medical Condition is "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part, or with respect to a pregnant woman who is having contractions that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or the unborn child' ... 3. Medical Screening Exam (MSE) is an exam within the capability of the hospital to determine whether an emergency medical condition exists. 4. Stabilization of an "emergency medical condition" should allow that no material deterioration of the condition is likely, within reasonable medical probability, from or during transfer of the individual from a facility. In pregnancy at-term, stabilization includes delivery of the child and the placenta (unless the latter cannot occur safely without transfer). ... V. Procedure 1. If an individual seeking emergency medical care comes to the hospital ' s Dedicated Emergency Department a QMP shall offer a Medical Screening Exam. If an individual seeking emergency medical care comes to any other portion of the hospital campus, including on-campus clinics, sidewalks, driveways, and parking lots, and requests emergency medical care, a QMP will offer a Medical Screening Exam to that person. Hospital property is the hospital's campus, defined as an area that is 250 yards around the main hospital building that are not a part of the hospital, such as physician offices, rural health centers, skilled nursing facilities, or other entities that participate separately in Medicare or restaurants, shops or other nonmedical facilities. In the absence of a request for emergency medical care made by the patient or their representative, a QMP medical screening exam will be offered if the Prudent Layperson Observer standard is met. 2. Under no circumstances shall the QMP or other staff inquire as to insurance status or method of payment of a patient seeking emergency treatment so as to delay the initiation of a Medical Screening Examination or further stabilizing treatment of that patient. 3. If necessary, following the Medical Screening Exam, QMPs shall offer further medical examination and treatment required to stabilize the medical condition within the hospital's resources."


A review of MR15 revealed the patient presented to the facility's Diagnostic Evaluation Center on October, 27, 2018 with complaints of abdominal pain, constant nausea, increased anxiety, and concern of adverse effects from current medication. The review of MR15 also revealed a psychiatric evaluation and completed lab work. However, further review revealed no vital signs charted in the medical record and no documentation that an appropriate medical screening examination was completed to rule out an emergency medical condition.

Interview with EMP15 on January 11, 2019, at 2:00 PM confirmed that MR15 did not have documentation of an appropriate medical screening examination.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on a review of facility policy, a tour of the facility and staff interview (EMP), it was determined the facility failed to maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition.


Findings include:


A review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated October 29, 2018, revealed, "... V. PROCEDURE ... 12. Each UPMC hospital Emergency Department shall maintain a list of physicians who are on call 24/7 to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition. Physicians on-call are required to personally attend to the patient when requested to do so by the treating physician or QMP. The on-call physician records are maintained similar to the medical record."


A tour of Diagnostic Evaluation Center (DEC, a dedicated emergency department) on January 8, 2019, at approximately 10:00 AM revealed an on-call list for psychiatry and internal medicine specialties. Upon further review it was noted that no other specialists were included on the list of physicians who are on call.

During an interview on January 8, 2019, at approximately 10:00 AM, with Charge Nurse EMP7, it was confirmed that no other specialists were included on the list of physicians who are on call for duty.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on a review of facility policy and documentation and staff interviews (EMP), it was determined that the facility failed to ensure a maintained central log on each individual who presented to the emergency department (ED) that include whether patients were medically stabilized prior to transfer for three of 22 medical records reviewed (MR2, MR3, and MR4).

Findings include:

A review of the faculty policy "UPMC Policy and Procedure Manual. Emergency Medical Treatment and Active Labor Act (EMTALA) " reviewed October 2018, revealed " ... V. Procedure: ...13. Each hospital facility shall maintain a log in the Emergency Department identifying each individual who seeks emergency medical treatment at that facility and indicate whether they refuse treatment, or whether they were transferred, admitted or discharged . These logs shall be retained for five years...." The facility policy did not include stabilization (prior to transfer) as information to be maintained on the Emergency Department log.

A review of MR2 on January 11, 2019, revealed the patient was transferred from the facility on 8/17/18, to a nearby hospital for evaluation. A review of the Emergency Department Log failed to include documentation that the patient was stabilized prior to transfer.

A review of MR3 on January 11, 2019, revealed the patient was transferred from the facility on 11/11/2018, to a nearby hospital due to pregnancy issues. A review of the Emergency Department Log failed to include documentation that the patient was stabilized prior to
transfer.

A review of MR4 on January 11, 2019, revealed the patient was transferred from the facility on 7/26//2018, to a nearby hospital due to pregnancy issues. A review of the Emergency Department Log failed to include documentation that the patient was stabilized prior to transfer.

Interview with EMP2 on January 11, 2019, at approximatley 1:30 PM confirmed the above findings.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on a review of facility policy and documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide an appropriate medical screening examination (MSE) to determine whether an emergency medical condition (EMC) existed for one of 22 medical records reviewed (MR15).

Findings include:

A review of facility policy and procedure "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated October 29, 2018, revealed, "Definitions ... 2. Emergency Medical Condition is "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part, or with respect to a pregnant woman who is having contractions that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or the unborn child' ... 3. Medical Screening Exam (MSE) is an exam within the capability of the hospital to determine whether an emergency medical condition exists. 4. Stabilization of an "emergency medical condition" should allow that no material deterioration of the condition is likely, within reasonable medical probability, from or during transfer of the individual from a facility. In pregnancy at-term, stabilization includes delivery of the child and the placenta (unless the latter cannot occur safely without transfer). ... V. Procedure 1. If an individual seeking emergency medical care comes to the hospital ' s Dedicated Emergency Department a QMP shall offer a Medical Screening Exam. If an individual seeking emergency medical care comes to any other portion of the hospital campus, including on-campus clinics, sidewalks, driveways, and parking lots, and requests emergency medical care, a QMP will offer a Medical Screening Exam to that person. Hospital property is the hospital's campus, defined as an area that is 250 yards around the main hospital building that are not a part of the hospital, such as physician offices, rural health centers, skilled nursing facilities, or other entities that participate separately in Medicare or restaurants, shops or other nonmedical facilities. In the absence of a request for emergency medical care made by the patient or their representative, a QMP medical screening exam will be offered if the Prudent Layperson Observer standard is met. 2. Under no circumstances shall the QMP or other staff inquire as to insurance status or method of payment of a patient seeking emergency treatment so as to delay the initiation of a Medical Screening Examination or further stabilizing treatment of that patient. 3. If necessary, following the Medical Screening Exam, QMPs shall offer further medical examination and treatment required to stabilize the medical condition within the hospital's resources."


A review of MR15 revealed the patient presented to the facility's Diagnostic Evaluation Center on October, 27, 2018 with complaints of abdominal pain, constant nausea, increased anxiety, and concern of adverse effects from current medication. The review of MR15 also revealed a psychiatric evaluation and completed lab work. However, further review revealed no vital signs charted in the medical record and no documentation that an appropriate medical screening examination was completed to rule out an emergency medical condition.

Interview with EMP15 on January 11, 2019, at 2:00 PM confirmed that MR15 did not have documentation of an appropriate medical screening examination.