Nursing Investigation Results -

Pennsylvania Department of Health
UPMC PRESBYTERIAN SHADYSIDE
Patient Care Inspection Results

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UPMC PRESBYTERIAN SHADYSIDE
Inspection Results For:

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UPMC PRESBYTERIAN SHADYSIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of a Department of Human Services, Chapter 5100 Mental Health Procedures Act Survey conducted on February 26, 26, & 28, 2020 at UPMC Presbyterian Shadyside Hospital (Western Psychiatric Hospital campus). It was determined the facility was not in compliance with requirements of the Chapter 5100 Mental Health regulations.




 Plan of Correction:


5100.15 (1) REQUIREMENT Treatment Plan Content and Availability:State only Deficiency.
5100.15 CONTENTS OF TREATMENT PLANS

(a) A comprehensive individualized plan of treatment shall:
(1) Be formulated to the extent feasible, with the consultation of the patent. When appropriate to the patient's age, or with the patient's consent, his family, personal guardian, or appropriate other persons should be consulted about the plan.
Observations:

Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that the faciity failed to ensure that the patient's participation in the development of the treatment plan was documented for seven of 12 medical records reviewed (MR45, MR46, MR47, MR48, MR49, MR50, and MR51).

Findings include:

Review on February 28, 2020, of facility policy, "Treatment Plans/Interdisciplinary Plans of Care" dated 2019, revealed, "II. Documentation of the Master Treatment Plan...A.9. The patient shall sign a printed version of the initial master treatment plan as well as the reviews. Documentation should also indicate if the patient refused to review or discuss the plan, if the patient refused to sign or if the patient was clinically unable to sign or acknowledge the treatment plan."

Medical records were reviewed on February 26 and 27, 2020 and revealed the following:

MR45's Master Treatment Plan was dated September 9, 2019. The area for signature of patient or family member/caregiver was blank.
MR45's Master Treatment Plan was dated August 22, 2019. The area for signature of patient or family member/caregiver was blank.

MR46's Master Treatment Plan was dated August 29, 2019. The area for signature of patient or family member/caregiver was blank.
MR46's Master Treatment Plan was dated September 5, 2019. The area for signature of patient or family member/caregiver was blank.

MR47's Master Treatment Plan was dated September 7, 2019. The area for signature of patient or family member/caregiver was blank.
MR47's Master Treatment Plan was dated September 9, 2019. The area for signature of patient or family member/caregiver was blank.

MR48's Master Treatment Plan was dated October 14, 2019. The area for signature of patient or family member/caregiver was blank.
MR48's Master Treatment Plan was dated October 15, 2019. The area for signature of patient or family member/caregiver was blank.

MR49's Master Treatment Plan was dated July 11, 2019, The area for signature of patient or family member/caregiver was blank.
MR49's Master Treatment Plan was dated July 15, 2019. The area for signature of patient or family member/caregiver was blank.
MR49's Master Treatment Plan was dated July 18, 2019. The area for signature of patient or family member/caregiver was blank.

MR50's Master Treatment Plan was dated August 12, 2019. The area for signature of patient or family member/caregiver was blank.

MR 51's Master Treatment Plan was dated September 8, 2019. The area for signature of patient or family member/caregiver was blank.
MR51's Master Treatment Plan was dated September 11, 2019. The area for signature of patient or family member/caregiver was blank.
MR51's Master Treatment Plan was dated September 16, 2019. The area for signature of patient or family member/caregiver was blank.

None of the above treatment plans indicated if the patient refused to review or discuss the plan, refused to sign, or was clinically unable to sign or acknowledge the plan.

During an interview on February 28, 2020, at 9:20 AM, EMP1 confirmed that the above master treatment plans were not signed by the patient and this is the facility's process to ensure the patient is aware of their treatment plan.














 Plan of Correction - To be completed: 04/04/2020

Under the direction of the Director of Nursing the following steps will be taken to ensure all patients are provided the opportunity to sign their treatment plan:
1. A nurse will complete the treatment plan in the Electronic Health Record (EHR) upon admission and each week following admission.
2. A member of the treatment team will print the Master Treatment Plan from the HER.
3. A member of the treatment team will review the plan with the patient and have the patient sign the Printed Master Treatment Plan.
4. A member of the treatment team will document in the EHR in the Master Treatment Plan that a signature was obtained.
5. If the patient refuses to sign following review, is clinically unable to sign following review, or refuses to review the plan, the nurse, or designee, will document in the EHR in the Master Treatment Plan the reason a signature was not obtained.
6. Staff will be provided a read and sign education on including the Patient in the Plan of Care beginning 3/23/2020 and completed by 4/3/2020
7. Monitoring will occur on 5 charts per unit each week beginning April 4, 2020

1 (a)(b)(c)(d) REQUIREMENT Article VI - Permissable Procedures:State only Deficiency.
ARTICLE VI
PERMISSIBLE SPECIALIZED
AND
PROHIBITED TREATMENT PROCEDURES

Statement of Principle
Every patient shall only receive approved treatment procedures in accordance with Departmental regulations. This treatment shall be described in his individualized treatment plan and shall be explained to the patient.

1. Permissible procedures
a. emergency provisions
b. routine care
c. examination by the court
d. any voluntary patient agree to participate; refusal may be grounds for discharge
Observations:

Based on a review of facility documentation and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a second opinion was documented for patients ordered treatment over objection for two of three medical records reviewed (MR2 and MR3).
Findings include:
Review of Mental Health Bulletin, issued date of March 11, 1985, and effective date of April 11, 1985, Number 99-85-10, stated "Subject Administration Of Psychotropic Medication to Protesting Patients ... (3) If the patient continues to refuse medication, obtain a second opinion from a psychiatrist concerning the degree of medical necessity/ advisability for the medication. The psychiatrist providing the second opinion may be a colleague of the treating psychiatrist. However , the second opinion should be based on an independent examination of the patient and an independent review of all medical records or tests."

Review of facility policy and procedure "Treatment Refusals/Mental Health" reviewed September 2019, revealed , "IV. Involuntary Patients: Non-Emergency Situations ... 3. If the patient continues to refuse medication, obtain a second opinion from a psychiatrist concerning the degree of medical necessity/advisability for the medication. Consideration should be given regarding the risk/benefit value of the medication if administered over protest, the reason(s) for the protest and alternative treatment approaches available. The psychiatrist providing the second opinion may be a colleague of the treating psychiatrist. However, the second opinion should be based on an independent examination and review of all medical records and tests. 4. If the consulting physician concurs that the protested medication is necessary, the medication may be administered over objection."

Review of MR2 revealed a physician order "Tx(treatment) over objection" dated May 3, 2019, at 13:03. Further review revealed no documented evidence a second opinion was obtained.
Interview with EMP2 on February 27, 2020, at 8:55 AM confirmed the above findings and revealed, "It [a second opinion[ is not there."

Review of MR3 revealed a physician order "Tx(treatment) over objection" dated June 25, 2019, at 13:07. Further review revealed no documented evidence a second opinion was obtained.
Interview with EMP2 on February 27, 2020, at 9:00 AM, confirmed the above findings and revealed, "it does't say over objection."










 Plan of Correction - To be completed: 04/01/2020

Under the direction of the Associate Chief, UPMC Western Psychiatric Hospital Inpatient Services:

Effective 4/1/2020 Physicians will utilize the MD consult order in the EHR to indicate a second opinion for treatment over objection is needed
Effective 4/1/2020, the consulting physician will utilize a "second opinion consult" note in the EHR type to complete the consult note documentation
Education will be provided to all physicians via a read and sign and completed by 3/30/2020
All second opinion orders will be audited for 90 days beginning 4/1/2020


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