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Based on a review of facility documents, medical records (MR) and employee interview (EMP), it was determined that the facility failed to ensure the documentation of ongoing clinical assessment, every two hours for the patient in restraints in three of five medical records (MR2, MR3, and MR4).

Findings include:

On January 9, 2025, a review of policy HS-NA0416, "Restraint and Seclusion" (Last Reviewed: July 30, 2024) was completed and revealed the following: Section "VIII. Use of Restraint for Non Violent/Non Self- Destructive Behavior D. Ongoing Patient Assessment and Care Interventions: 4. The continued need for the use of restraint for Non Violent/ Non Self- Destructive behavior will be reassessed and documented in the medical record at the following frequencies or more often as the patient condition requires. (a)_Non Violent/ Non Self- Destructive behavior - every 2 hours 5. The documented assessment may include but will not be limited to: a. Release of restraint; b. Color, sensation and movement of the involved extremity(ies); c. Skin integrity/signs of injury; d. Readiness for restraint discontinuation based on observed behaviors: e. Alternatives provided to the patient."


On January 9, 2025, a review of MR2 revealed the patient was placed in soft wrist restraints on January 6, 2025, at 3:05 PM. There is no evidence of the required two hour re-assessment on January 9, 2025, at 10:00 AM and 12:00PM. There is no evidence/documentation that the restraint was discontinued in the medical record.


On January 9, 2025, a review MR3 revealed that the patient was placed in soft wrist restraints on October 18, 2024, at 5:01 PM. There is no evidence of the required two hour re-assessment on October 18, 2024 at 10:00 PM; on October 19, 2024 at 6:00 AM, 4:00 PM, and 6:00 PM; on October 20, 2024 at 6:00 AM; and on October 21, 2024 at 12:00 PM and 2:00 PM.


On January 9, 2025, a review MR4 revealed that the patient was placed in soft wrist restraints on November 23, 2024, at 6:48 PM. There is no evidence of the required two hour re-assessment on November 24, 2024, at 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, and 6:00PM. There is no evidence/documentation that the restraint was discontinued in the medical record by the nursing staff.

On January 9, 2025, EMP1 confirmed the above findings between 1:15 PM and 1:29 PM.

Based on a review of facility documents, medical records (MR), observation, and staff interview(EMP), it was determined that the facility failed to supervise the patient's care to ensure the patient's cardiac status was being monitored at all times for one of ten medical records reviewed (MR1).

Findings include:


On January 9, 2025, a review of the policy, "Telemetry Monitoring" (HS-HD-CP-22; Last Reviewed: September 4, 2024, was completed and revealed the following: "I. Policy: It is the policy of UPMC to provide standardized, consistent care of patients undergoing continuous cardiac monitoring ...IV: Procedure: 1. Monitor Orders and Association: a. Monitor Orders and Evaluation: 1. A physician and/or the advanced practice provider will assess the need and provide the order for the cardiac rhythm monitoring ... b. Monitor Associations 1. Confirm cardiac monitor order 2. Upon admission to the designated area, the patient who is ordered cardiac rhythm monitoring will be connected to the bedside monitor and/or telemetry, as is appropriate to the unit monitoring system 3. Associate the telemetry product with the patient by confirming the telemetry equipment number and verify correct patient identifiers 4. Confirm monitor is in view in all necessary locations. Section 4. Cardiac Monitor Nursing Documentation: a. Electronic Health Record Documentation: 1. The patient's cardiac rhythm waveform will be documented at transition or handover of care personnel and with any condition change that requires provider notification. b. Printed Cardiac Waveform Documentation: 1. Cardiac rhythm will be captured upon admission to the designated area and with any condition change that requires provider notification."


On January 9, 2025, a review of Policy MCK-PE1020, "Assessment/Reassessment of Patients" (Last Reviewed: May 2024) was completed and revealed the following ..."Then Nurse should complete a reassessment as frequently as indicated by patient's condition, complexity of patient's needs, and the need to provide continuity of care. ...While the collection of reassessment data may be delegated to an authorized staff member, provided it is within the staff members' scope of practice, the responsibility and accountability for collecting and analyzing the reassessment data and the modification sofa patient specific plan of care remains with the professional nurse"...




On January 9, 2025, a review of MR1 revealed that the patient was admitted on December 11, 2024, and was a 76-year-old, with a history of Asthma, Benign Prostatic Hypertrophy, COPD, GERD, Rectal Adenocarcinoma, Periperal Vascular Disease, Aortic Stenosis and Hypertension. MR1 was admitted after presenting to the Emergency Department with cough, fatigue, and chest discomfort that been going on for eight days prior to coming to the hospital. MR1 described the feeling as an anterior chest sensation that occasionally radiated to his back and coughing up clear colored sputum but denied fever or chills. MR1 was admitted to the hospital with a diagnosis of Influenza A, and Elevated Troponin of 7000, and Chest Heaviness. The electrocardiogram revealed an ST elevation, and the initial impression was Pericarditis. On December 11, 2024, the admitting physician ordered continuous cardiac monitoring. The initial reading on the cardiac monitor was normal sinus rhythm (NSR). Cardiology was consulted to see MR1 while in the hospital.



On December 12, 2024, at 5:33 AM, a Condition A was called for MR1. Upon arrival of the Code Team, CPR was initiated. A review of the monitor revealed that the patient came off the monitor at 3:30 AM. The Code Team continued cardiopulmonary management for a total of twenty-two minutes and performed eleven cycles of CPR. Despite these interventions, the patient remained in asystole and had no pulse at each rhythm and pulse check. After twenty-two minutes of resuscitation the patient was pronounced dead at 5:59 AM. MR1's spouse was notified, and the preliminary cause of death was Viral Myopericarditis and Influenza A.


Further review of MR1 revealed no documentation to support that an RN supervised nursing care or reassessed the patient from 3:00AM until 5:33 AM when MR1 was found off the cardiac monitor and asystole.



On January 9, 2024, the above findings were confirmed at 11:15 AM by EMP1.

Based on a review of facility documentation, medical record (MR), and employee interview (EMP), it was determined the facility failed to ensure staff adhered to the policies and procedures of the hospital for the cardiac monitoring in one of ten medical records (MR1).

Findings include:

On January 9, 2025, a review of the policy, "Telemetry Monitoring" (HS-HD-CP-22; Last Reviewed: September 4, 2024, was completed and revealed the following: "I. Policy: It is the policy of UPMC to provide standardized, consistent care of patients undergoing continuous cardiac monitoring ...IV: Procedure: 1. Monitor Orders and Association: a. Monitor Orders and Evaluation: 1. A physician and/or the advanced practice provider will assess the need and provide the order for the cardiac rhythm monitoring ... b. Monitor Associations 1. Confirm cardiac monitor order 2. Upon admission to the designated area, the patient who is ordered cardiac rhythm monitoring will be connected to the bedside monitor and/or telemetry, as is appropriate to the unit monitoring system 3. Associate the telemetry product with the patient by confirming the telemetry equipment number and verify correct patient identifiers 4. Confirm monitor is in view in all necessary locations. Section 4. Cardiac Monitor Nursing Documentation: a. Electronic Health Record Documentation: 1. The patient's cardiac rhythm waveform will be documented at transition or handover of care personnel and with any condition change that requires provider notification. b. Printed Cardiac Waveform Documentation: 1. Cardiac rhythm will be captured upon admission to the designated area and with any condition change that requires provider notification."


On January 9, 2025, a review of Policy MCK-PE1020, "Assessment/Reassessment of Patients" (Last Reviewed: May 2024) was completed and revealed the following ..."Then Nurse should complete a reassessment as frequently as indicated by patient's condition, complexity of patient's needs, and the need to provide continuity of care. ...While the collection of reassessment data may be delegated to an authorized staff member, provided it is within the staff members' scope of practice, the responsibility and accountability for collecting and analyzing the reassessment data and the modification sofa patient specific plan of care remains with the professional nurse"...




On January 9, 2025, a review of MR1 revealed that the patient was admitted on December 11, 2024, and was a 76-year-old, with a history of Asthma, Benign Prostatic Hypertrophy, COPD, GERD, Rectal Adenocarcinoma, Periperal Vascular Disease, Aortic Stenosis and Hypertension. MR1 was admitted after presenting to the Emergency Department with cough, fatigue, and chest discomfort that been going on for eight days prior to coming to the hospital. MR1 described the feeling as an anterior chest sensation that occasionally radiated to his back and coughing up clear colored sputum but denied fever or chills. MR1 was admitted to the hospital with a diagnosis of Influenza A, and Elevated Troponin of 7000, and Chest Heaviness. The electrocardiogram revealed an ST elevation, and the initial impression was Pericarditis. On December 11, 2024, the admitting physician ordered continuous cardiac monitoring. The initial reading on the cardiac monitor was normal sinus rhythm (NSR). Cardiology was consulted to see MR1 while in the hospital.



On December 12, 2024, at 5:33 AM, a Condition A was called for MR1. Upon arrival of the Code Team, CPR was initiated. A review of the monitor revealed that the patient came off the monitor at 3:30 AM. The Code Team continued cardiopulmonary management for a total of twenty-two minutes and performed eleven cycles of CPR. Despite these interventions, the patient remained in asystole and had no pulse at each rhythm and pulse check. After twenty-two minutes of resuscitation the patient was pronounced dead at 5:59 AM. MR1's spouse was notified, and the preliminary cause of death was Viral Myopericarditis and Influenza A.


Further review of MR1 revealed no documentation to support that an RN supervised nursing care or reassessed the patient from 3:00AM until 5:33 AM when MR1 was found off the cardiac monitor and asystole.



On January 9, 2024, the above findings were confirmed at 11:15 AM by EMP1.