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UPMC ALTOONA 620 HOWARD AVENUE ALTOONA, PA 16601 March 19, 2020
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on a review of facility documents, medical records (MR) and staff interview (EMP), it was determined that UPMC Altoona failed to provide care in a safe setting by failing to follow established policy and procedures in providing care for 1 of 1 mental health patient seeking emergency medical care. (MR1)

Findings

UPMC Altoona Observation of Behavioral Health Patients Guidelines, Dated 6/28/17, Section: Emergency Department, Effective Date: 7/5/17. Subject: Observation of Behavioral Health Patients. "Purpose: To ensure the safety of behavioral health patients seeking care and evaluation in the Emergency Department by protecting them from their self and others through appropriate observation. Policy: 1. Patients who are identified as moderate or high risk for suicide will be placed in constant observation. All patients are screened at triage for risk of suicide. ... 5. Patient clothing will be removed except undergarments and the patient will be placed in a gown. ... revised 4/24/19"

1. A review of MR1 "Emergency Department ... Chief Complaint: Overdose. Focused Assessment of Complaints: took 25-30 25mg Trazodone ... Suicide/Homicide Risk Screening: In the past month, including today, have you had any thoughts or plans about hurting or killing yourself: Yes ... Suicide/Homicide Screen: Positive."
Further review of MR1 revealed no documented evidence that the patient was placed in constant observation or changed into a hospital gown.

2. During an interview with EMP6 it was revealed that EMP6 stopped and informed the Charge Nurse that the patient was a completed 302 and needed a change of clothes and a sitter.

3. During an interview with EMP1 it was confirmed that the patient was never placed in a hospital gown or on constant observation.