The Pennsylvania Department of Health has cited UPMC Montefiore for deficiencies in its patient assessment and building safety systems when an 89-year-old dementia patient died on the hospital's rooftop last month.

A health department spokeswoman said yesterday that no penalties accompanied the report of deficiencies, and officials are still reviewing whether to impose any licensing action or fine. Deficiencies commonly result from state investigations, with facilities required to make changes to avoid repeating problems, but penalties are rarer.

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.

She reached the roof through the door of a 13th floor mechanical room, which had a broken lock, according to the state report.

The Allegheny County medical examiner has yet to make a ruling in her death, and an official said yesterday that is because results of blood tests are pending.

The state health department's report, based on visits to the facility in early December, said the hospital failed to take proper steps to assess its patient's safe care needs; there was no indication of any special steps to address her wandering behavior; and it risked her safety by allowing access to the roof.

"Based on review of facility policy and medical record, and staff interviews, it was determined that facility staff failed to implement a plan of care to provide safe, efficient and therapeutically effective nursing care," the report stated.

It also said "the facility failed to maintain the hospital environment in a manner that the safety and well-being of patients is assured."

The report said the hospital failed to take note of Mrs. Diggs' history of wandering by adopting any special means of monitoring her to prevent it. State investigators found no evidence that an assessment of her needs was completed upon her admission.

"There is no documented admission assessment in the record," a hospital employee told investigators on Dec. 8, according to the report. "There should have been documentation of the wandering ... it is not in there."

Health Department spokeswoman Stacy Kriedeman said UPMC submitted an acceptable plan of correction Jan. 9 addressing the various issues raised in the report. A decision on whether any penalties will be imposed depends, in part, on how good a job the hospital does of implementing changes to prevent future incidents, Ms. Kriedeman said.

She said inspectors have not yet revisited UPMC Montefiore to check on those changes.

UPMC officials noted in a statement yesterday that they adopted a new plan in December to undertake prompt and extensive searches for any patients missing from their units. Known as "Condition L," a hospital-wide alert is to be announced, with every available employee joining in a coordinated search of the hospital complex.

That new alert system was used four times in the first half of January with patients quickly located in each case, said hospital spokesman Frank Raczkiewicz. None of those was a dementia patient, he said.

Also, the hospital's geriatric or psychiatric nurses are to make specific assessments of the potential for wandering among patients, with individual care plans developed for those at risk. And new policies have been instituted to inspect doors leading to roofs and mechanical areas.

"UPMC is confident that these initiatives will further ensure the safest environment possible for our patients," the hospital's statement said.

In addition to the state investigation, the Allegheny County district attorney's office is reviewing whether any criminal charges should be filed related to Mrs. Diggs' death, and a civil suit is planned by Mrs. Diggs' family.

The family's attorney, Robert Peirce III, said the state's findings will be helpful to a civil case.

"I think these citations have confirmed what our own investigation has revealed," he said, "that there were numerous violations involving Mrs. Diggs' care at a UPMC facility, that this situation was avoidable, and, unfortunately, the lack of care she received there led to her death."