UPMC Cited by Health Department for Death on Rooftop
The state regulatory agency's investigation followed the death of Rose Lee Diggs, a former Homewood resident who had been transferred to the hospital from the Village at Pennwood nursing home Nov. 29. The nursing home notified the hospital upon Mrs. Diggs' admission that she was known to wander, the state's report said. Mrs. Diggs' body was found on UPMC Montefiore's roof at 8 a.m. Dec. 3, more than 13 hours after she was last seen one story below, in her 12th-floor room. She was wearing a hospital gown and slippers on a night in which temperatures fell into the 20s.
According to the state health department's report, UPMC failed to take proper steps to assess its patient's safe care needs; there was no indication of any special steps to address the deceased patient's wandering behavior; and it risked her safety by allowing access to the roof. The report stated that "Based on review of facility policy and medical record, and staff interviews, . . . facility staff failed to implement a plan of care to provide safe, efficient and therapeutically effective nursing care." The report also stated that UPMC "failed to maintain the hospital environment in a manner that the safety and well-being of patients is assured." The report said UPMC failed to take note of Mrs. Diggs' history of wandering by adopting any special means of monitoring her to prevent it. There was no evidence that an assessment of her needs was completed upon her admission.