HospitalInspections.org

Based on a review of facility documents, medical records (MR) and employee interviews (EMP), it was determined that the facility failed to maintain a safe environment for psychiatric patients for one of ten medical records reviewed (MR4).


Findings include:


On August 21, 2025, a review of policy, HS-HD-AP-07, "Assessing Patient for Suicide Risk" was completed and revealed the following: I. POLICY/PURPOSE: It is the policy of UPMC to recognize the importance of screening & assessing for risk of suicide, initiate reasonable precautions to minimize the chance of a patient killing themselves and to create a safe environment... IV. Procedure: ...1. High Risk Patients (Bullet 3)Utilize a ligature resistant bathroom, and if not available, observe the patient while the patient is in the bathroom. (Bullet 4) Assess physical environment and remove contraband, including unsafe items not necessary for patient care... (Bullet 5) When appropriate, place patient in hospital attire.



On August 13, 2025, a review of MR4 revealed a 70 year old male who was admitted to the hospital on June 30, 2025 with a diagnosis of suicidal ideation and the patient himself was asking for inpatient admission and asking for safety. MR4 reported that he had been very depressed for four months since his son and his dog suddenly died. He denied delusions but expressed that he had several plans for suicide and was worried for his safety. His suicide risk assessment was completed and he was scored as a high risk. He was on metoprolol, lisinopril, Atorvastatin, lasix and had a history of sleep apnea requiring CPAP.


The facility document revealed on July 6, 2025, that while he was in the hospital, MR4 had a plan to hang himself from the CPAP supplies found in the bedroom as well as with the CPAP cords from the machine left in the room. In addition, a visitor found a baggie of crack in his room. The information was relayed to the hospital leadership and security and MR4 was changed into hospital clothing and remained in hospital clothing until the time of discharge. MR4 remained in the hospital for additional care and treatment.


Interview with EMP1, at 1:10 PM, confirmed that the facility failed to remove unsafe items from the room as per policy.


On August 13, 2025, at 1:15 PM, EMP1 confirmed the above.