Pennsylvania Department of Health
UPMC SOUTH SURGERY CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
UPMC SOUTH SURGERY CENTER
Inspection Results For:

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UPMC SOUTH SURGERY CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of a State licensure survey conducted on October 11, 2023, with continued document review on October 16, 2023, at UPMC South Surgery Center. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.




 Plan of Correction:


553.3 (1) LICENSURE Governing Body Responsibilities:State only Deficiency.
553.3
Governing Body responsibilities include:

(1) Conforming to all applicable Federal, State, and local laws.

Observations:

Based on a review of facility documentation, medical record review (MR), and staff interviews (EMP), it was determined that the facility failed to conform to all applicable state and local laws.


UPMC South Surgery Center was not in compliance with the following State law:?


A review of "Act 13 of 2002 MEDICAL CARE AVAILABILITY AND REDUCTION OF ERROR (MCARE) ACT...Act of Mar. 20, 2002, P.L. 154, No. 13 40" on October 12, 2023, revealed, "Section 308. (a) Reporting. --A health care worker who reasonably believes that a serious event or incident has occurred shall report the serious event or incident according to the patient safety plan of the medical facility unless the health care worker knows that a report has already been made.? The report shall be made immediately or as soon thereafter as reasonably practical, but in no event later than 24 hours after the occurrence or discovery of a serious event or incident."


This was not met as evidenced by:


Based on a review of facility documentation and medical records (MR), and staff interview (EMP), it was determined that staff failed to report serious events according to the patient safety plan of the medical facility, for six of eight facility occurrences reviewed (MR11, MR13, MR14, MR16, MR17, MR18).


Findings include:


On October 12, 2023, A review of the facility, "Patient Safety Plan," revised date, April 2023, revealed, "V. Summaries of Key Elements of Patient Safety Program:? A.? Internal Reporting System: ...ii. The basic elements of the reporting system are: An initial incident/Event Report is generated by the individual discovering any reportable patient event. The staff will immediately communicate any significant event that could be a serious event ... Staff members or employees may be subject to disciplinary action if they knowingly make false statements in a report, knowingly cause a false report to be filed or fail to report a Serious Event with knowledge of the event and the obligation to report."


On October 12, 2023, a review of the facility occurrences revealed that MR11 had a date of service of February 23, 2023, for a right carpal cubital tunnel. Further review revealed that the patient notified surgeon EMP4 on March 1, 2023, for drainage from the elbow and an open incision. On March 3, 2023, MR11 returned to surgery and had an Incision and Drainage of the right elbow and was diagnosed as a wound dehiscence. Further review revealed that EMP4 communicated the serious event to the facility on March 14, 2023. The serious event was confirmed on March 14, 2023 and the facility reported the serious event on March 15, 2023.



During an interview on October 12, 2023, at 12:58 PM, EMP1 confirmed surgeon EMP4 knew of the infection on March 3, 2023 but did not notify the facility of the serious event until March 14, 2023.



On October 12, 2023, a review of the facility occurrences revealed that MR13 had a date of service of February 23, 2023, for a right ulnar nerve transfer and right ulnar nerve decompression of the elbow. Further review revealed that the patient notified surgeon EMP4 on March 2, 2023, and reported hand and fingers reddened with drainage. MR13 was seen in EMP4's office and serosanguinous fluid was expelled. An x-ray revealed a hematoma volar soft tissue of the distal forearm. MR13 was transported via EMS to local hospital for surgical intervention. MR13 had a right forearm hematoma evacuation. Further review revealed that EMP4 communicated the serious event to the facility on March 15, 2023. The serious event was confirmed on March 15, 2023 and the facility reported the serious event on March 16, 2023.


During an interview on October 12, 2023, at 1:06 PM, EMP1 confirmed EMP4 knew of the surgical complications on March 2, 2023 but did not notify the facility of the serious event until March 15, 2023.



On October 12, 2023, a review of the facility occurrences revealed that MR14 had a date of service of December 30, 2022, for a right knee arthroscopic assisted ACL reconstruction with bone patellar. Further review revealed that the patient notified surgeon EMP5 on February 7, 2023, with complaints of redness and warmth and drainage and Bactrim was prescribed. On March 7, 2023, MR14 returned to surgery and had an Incision and Drainage with scar revision of the right knee. On March 9, 2023, MR14 returned to surgery for a wound dehiscence. Further review revealed that EMP5 communicated the serious event to the facility on, March 9, 2023. The serious event was confirmed on March 9, 2023 and the facility reported the serious event on March 9, 2023.



During an interview on October 12, 2023, at 1:08 PM, EMP1 confirmed EMP5 knew of the infection on February 7, 2023 but did not notify the facility of the serious event until March 9, 2023.


On October 12, 2023, a review of the facility occurrences revealed that MR16 had a date of service of April 25, 2023, for a right ring finger release. Further reveal revealed that the patient notified surgeon EMP4 on May 3, 2023, with odor and pain. On May 4, 2023, MR16 was seen in the surgeon's office and the wound's appearance was white borders with mild erythema. MR16 was treated with antibiotics. Further review revealed that EMP4 knew of the infection on May 4, 2023 and did not communicate the serious event to the facility. The serious event was reported to the facility by the UPMC system Infection Control Committee and the report was dated May 31, 2023. Confirmation occurred on May 31, 2023 and the serious event report was completed.



During an interview on October 12, 2023, at 1:13 PM, EMP1 confirmed EMP4 knew of the infection on May 4, 2023 and the information was relayed via the Infection Control Report on May 31, 2023 and the facility was not notified of the serious event until May 31, 2023.



On October 12, 2023, a review of the facility occurrences revealed that MR17 had a date of service of April 18, 2023, for a right cubital tunnel surgery. On May 4, 2023, the patient was seen by the surgeon EMP6, for complaints of a purple hand. On May 8, 2023, the surgeon ordered a doppler study that revealed an upper extremity blood clot, positive acute DVT to one of the paired brachial veins and was started on anticoagulants. Further review revealed that EMP6 communicated the serious event to the facility on May 22, 2023. The serious event was confirmed on May 22, 2023 and the facility reported the serious event on May 22, 2023.


During an interview on October 12, 2023, at 1:15 PM, EMP1 confirmed EMP6 knew of the surgical complications on May 4, 2023 but did not notify the facility of the serious event until May 22, 2023.



On October 12, 2023, a review of the facility occurrences revealed that MR18 had a date of service of June 9, 2023, for a right knee ACL with quadricep tendon autograft surgery. On June 15, 2023, the patient had an appointment with the surgeon EMP5 and was diagnosed as a knee effusion. The patient had another appointment with EMP5 on July 19, 2023, for fever, chills, and pus from the incision. On July 25, 2023, MR18 had surgery for an Incision and Drainage of a wound dehiscence. Further review revealed that EMP5 communicated the serious event to the facility on July 25, 2023. The serious event was confirmed on July 25, 2023 and the facility reported the serious event on July 25, 2023.



During an interview on October 12, 2023, at 1:18 PM, EMP1 confirmed EMP5 knew of the surgical complications on June 15, 2023 but did not notify the facility of the serious event until July 25, 2023.


During an interview on October 12, 2023, at 1:20 PM, EMP1 confirmed EMP4, EMP5 and EMP6 reported serious events to the facility more than 24 hours after the occurrence or discovery of the serious event or incident.?













 Plan of Correction - To be completed: 02/01/2024

The deficiency was immediately reviewed with the President, Sr, Director Patient Safety, Innovation & Quality, Director Robotics &Clinical Operations, Sr. Director Patient Safety & Regulatory Oversight, PAG Center Quality Improvement-Innovation, Sr. Director, Corporate Risk Management and UPMC South Surgery Center Leadership on 12/04/23.
Intervention
All providers that operate at the UPMC South Surgery Center will be notified by letter of the expectations for immediate notification to the UPMC South Surgery Center of patient complications post procedure.
Education
Education will be provided to all providers that operate at UPMC South Surgery Center via email and read receipt or in person sign off surrounding the expectation of notification process to the UPMC South Surgery Center for when provider first become aware of any post-surgical complications.
Education will be provided to UPMC South Surgery Patient Safety Team regarding the 2023 Patient Safety Plan and reporting requirements to the PA Patient Safety Authority of Serious Events.

Completion date: The education will be completed by January 26, 2024.

Monitoring:

Director of the UPMC South Surgery Center will be responsible for monitoring compliance with the providers who operate at the UPMC South Surgery Center notifying the UPMC South Surgery Center when the provider first become aware of any post-surgical complications.

Monitoring will be performed by auditing every complication notification weekly received with the date of discovery by the provider and the date of notification to UPMC South Surgery Center.

Reporting:

On a weekly basis, audit results will be shared with the UPMC Leadership team including Medical Director, Director and clinicians for review and follow-up.
Every other month, compliance results will be shared at the PUH/SHY Quality and Safety Surgical Cabinet and the PUH/SHY Quality and Safety Medicine Cabinet Meetings
The Director and will be responsible for overseeing the correction of this deficiency.


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