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Based on review of personnel records and staff interviews, the hospital did not ensure that personnel are properly licensed and qualified for their title and position. Specific reference is made to Staff #he psychiatric unit must provide through the use of qualified personnel, the following: psychology, social work, psychiatric nursing, occupational and recreational services.

A review of the hospital job description of the Director of Psychiatric Nursing Services revealed that the person must be a registered nurse who has a master's degree in psychiatric and mental health nursing, or its equivalent, from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill. The Director must demonstrate competence to participate in interdisciplinary formulation of individual treatment plans, give skilled nursing care and therapy, and to direct, monitor, and evaluate the nursing care furnished.

During interview with Staff #5 on 9/5/14 at 2:00 PM, it was revealed that Staff #6 has worked as the Director of Nursing for Psychiatric Services since September 2012.

Staff #6 the Director of Nursing for Psychiatric Services personnel records were reviewed. Staff #6 holds a Bachelor's degree in Nursing, and Bachelor degree in Psychology. Staff #6 does not have a master's degree in Psychiatric or Mental Health Nursing or its equivalent. Therefore, the current Director of Nursing for Psychiatric Services of the Behavioral Health Program is not qualified in accordance with accepted standards of practice for Psychiatric Units.

Based on medical record reviews and administrative staff interviews, it was determined that the facility failed to ensure that a patient was provided with appropriate and timely care. This was found in 1 of 9 medical records reviewed at the Mid-Hudson Valley Division of Westchester Medical Center. Specific reference is made to patient #1.

Findings include:

1. Consultations were not conducted in a timely manner. A review of medical record #1 on August 22, 2014, revealed a police officer brought this forty-eight year old patient to the facility on June 28, 2014 because she was living at a train station.

The patient's previous medical history was significant for Schizoaffective Disorder, Bipolar type, Hypertension, and Asthma. The patient had previous psychiatric admissions which included February 21, 2013, August 15, 2013 and December 11, 2013. For the latter admission, the patient was discharged from the facility on February 11, 2014. The patient's Axis V (Global Assessment of Functioning or GAF, a numeric scale of 1 through 100 used by mental health clinicians and physicians to rate subjectively the social, occupational, and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems-in-living.) was 30, down from 50 on February 11, 2014, when she was last discharged. A neurology consultation was not performed until August 1, 2014.

[Note: the GAF scale is as follows:

91 - 100 No symptoms. Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities.

81 - 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns.

71 - 80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).

61 - 70 Some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.

51 - 60 Moderate symptoms (e.g., flat affect and circumlocutory speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).

41 - 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job, cannot work).

31 - 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed adult avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).

21 - 30 Behavior is considerably influenced by delusions or hallucinations or serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends).

11 - 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute).

1 - 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.

0 Inadequate information.]


Review of the medical record revealed that the patient was admitted to the Behavioral Health Unit on June 29, 2014 for "worsening thought disorder and difficulty functioning." The patient complained of headaches which peaked at a score of 10 on a scale of 0 (no pain) to 10 (most severe pain). A CT-Scan (X-ray computed tomography, is a technology that uses computer-processed x-rays to produce tomographic images or virtual 'slices' of specific areas of the scanned object, allowing the user to see inside without cutting) of the head was done on July 15, 2014 which indicated the patient had a history of chronic headaches.

According to the medical record the neurologist assessed the patient on August 1, 2014 and identified diffuse cognitive impairment with problems with attention, memory and calculation. In addition the patient had tremors of the limbs deemed consistent with Depakote (one of a number of different brand names for an anticonvulsant and mood stabilizing drug used primarily in the treatment of epilepsy, bipolar disorder and prevention of migraine headaches) use. The neurologist recommended "screening laboratory tests,"a magnetic resonance imaging (MRI) and an electroencephalography (EEG). Blood tests were performed on August 10, 2014, nine days after the neurologist recommendation. These tests were not done timely. Furthermore, up to August 22, 2014 at approximately 2:00 PM, when the medical record was reviewed, the MRI and EEG had not been performed.

During interview these findings were verified with the Director of the Behavioral Health Unit on August 22, 2014.


2. The medical record also notes the patient's platelet (platelets or thrombocytes, are blood cells whose function is to stop bleeding) count was 169 on admission, but decreased to 142 on August 10, 2014, 121 on August 21, 2014, and 117 on August 23, 2014 [the adult normal range is 150-400 thousand cells per microliter (K/uL)]. A hematology consultation done on August 22, 2014 at 8:54 PM revealed that the patient had thrombocytopenia (a relative decrease of platelets in blood, or a platelet count below 50,000 per microlitre) "back to 8/10/14" and that the patient "developed absolute neutropenia" (a disorder characterized by an abnormally low number of neutrophils - neutrophils usually make up 60 to 70% of circulating white blood cells and serve as the primary defense against infections by destroying bacteria in the blood) "since 8/21/14." The hematologist also noted chronic intermittent diarrhea for 1 year, but this was not identified or address in the physician assistant's assessment of the patient during the hospitalization. A gastroenterology consultation was conducted on August 23, 2014. These consultations were not performed in a timely manner given the above findings, and this led to a delay in treating the patient's thrombocytopenia.

3. Further review of the medical record revealed there was no documented evidence that the neurologist had performed a follow up assessment up to August 22, 2014 following the initial consultation on August 1, 2014.

The medical record review on August 25, 2014 revealed the EEG was done on August 24, 2014, three weeks after it was recommended. The test was "abnormal due to generalized background slowing indicative of diffuse cerebral dysfunction and excessive diffuse beta activity." Clinical correlation was recommended.

On August 19, 2014 the administrative staff provided for review a plan of correction (POC) for the March 17, 2014 survey. A review of the facility's plan of correction revealed the facility would ensure that medical care was appropriately provided in a timely manner, but it did not address the medical practitioners' inadequate history and physical assessments of their patients.

Based on observations, staff interviews and reviews of dietary policies and procedures, the Food Service Director did not ensure that the daily operation of the food service department is maintained in a sanitary manner.

Findings include:

A tour of 2 hospital kitchens was conducted on August 19, 2014 and September 2, 2014 at approximately 10:30 AM. The kitchens that were toured were Mid-Hudson Valley Division of Westchester Medical Center (August 19, 2014) and Westchester Medical Center (September 2, 2014). The surveyor was accompanied by the Food Service Director and Director of Operations at each facility. The Food and Nutrition Department at Mid-Hudson Valley Division of Westchester Medical Center is self-operated- it is not contracted. The Westchester Medical Center is managed by a contractor. Examples of issues observed, during the tours, included, but are not limited to, the following:
A. Unsanitary environment/ food safety findings at:

I - Mid-Hudson Valley Division of Westchester Medical Center

a) Plastic garbage cans throughout the kitchen were not covered despite not in use.

b) A floor model Hobart mixer was not in use and yet it was not covered.

c) Hand washing sinks were missing waste baskets to discard paper towels.

d) Cutting boards were discolored and had large groves. They needed to be replaced.

e) Two piles of sheet pans contained a liquid substance between the pans. The sheet pans had not been air dried.

f) A condiment rack had a multitude of commercial size plastic containers with spices. They were all opened yet they were not labeled as to when they were opened or when they would expire.

g) The ice scoop stand, where the ice scoop is stored, had gray stains throughout the receptacle.

h) The pot washing area was missing rubber mats to prevent falls.

i) The clean pots were stored next to the dirty pots in the pot washing area.

j) A mop was observed inside a yellow bucket. This bucket contained dirty water. This bucket was stored in the hot food production area.

k) A white commercial bin containing rice was not properly labeled. The rice was not the conventional rice, but the specialty parboiled rice.

l) Food labeling throughout the refrigerators and freezers were not documented appropriately.

All food items observed had only 1 date. The identification of the food items were not documented nor were expiration dates documented on the opened food items. During the observation, food service staff provided contradictory information regarding the date on the label. The Director of Food Service informed the surveyor that the date on the label was the expiration date, yet the Operation Manager informed the surveyor that the date indicated that after 3 days from the date on the label means the food must be discarded. Food items observed to have only 1 date were soups, chocolate puddings, Cole slaws, grenadine syrups and pans with cooked foods in the refrigerators. In addition, the facility does not have a policy on food labeling.

M) Review of temperature logs for the pantry refrigerators and freezers for the month of August 2014 on the Progressive Care Unit, 5 CK, 5 Cooke and 6 Cooke units noted no evidence of corrective action when the temperatures were out of range. The standard for refrigerator temperature is 40 degrees Fahrenheit and below. The standard for freezer temperature is 0 degree Fahrenheit and below.

The following are examples of temperatures in refrigerators and freezers in the pantries that were out of range and no intervention was noted to correct the problem of the temperatures that were out of range.

- Progressive Care Unit temperature log reads "Medication-Refrigerator/ Freezer Temperature Log." This form also states that the temperature range should be 36 to 46 degrees. Forty one degrees and above are not acceptable temperatures for food stored in a refrigerator.

The freezer was out of range 6 times (greater than 0 degrees Fahrenheit) in the month of August 2014 and the refrigerator temperature was out of range 22 out of 25 days in August 2014.

- Unit 5 CK temperature log reads "Temperature Record for Frozen Food." This form states` the freezer temperature range is -5 to 5 degrees. Freezer temperature standard is 0 degrees Fahrenheit and below not above 0 degree Fahrenheit. This log noted freezer temperature out of range 10 times in 25 days in August 2014. There was no evidence that corrective action was taken.

- Unit 5 Cooke temperature log reads "Temperature Record for Refrigerated Food." This form states that the refrigerator temperature should be maintained at 41 degrees. The temperature in this refrigerator was out of range 9 out of 25 days in August 2014. Corrective action was not noted.

It was observed that in addition to temperatures found to be out of range in the refrigerator and freezer, the forms utilized on these units to record daily temperatures were all different and they contained different temperature ranges.

II. Westchester Medical Center

a) During tours of the kitchen it was observed that the freezer temperature was 11 degrees Fahrenheit in August 2014. The freezer temperature did not meet the National Food standard temperature for a freezer. The standard is 0 degrees Fahrenheit and below.

On 9/5/14 the Food Service Director informed the surveyors that food was discarded and the Food Service Director and the Engineering Department called for the repair of the freezer. It was found that the coils in the motor were frozen and hence the motor could not maintain the required 0 degree Fahrenheit to keep the food frozen.

b) During the tour of the kitchen on 9/2/14 it was observed that there were 2 air curtain refrigerators in the kitchen. In the first air curtain refrigerator the surveyor touched the shelf containing the milk, the shelf felt warm. The temperature of the air curtain refrigerator was 60 degrees Fahrenheit. The containers of milk also felt warm. The temperature inside a container of milk was 55 degrees Fahrenheit. The second air curtain refrigerator had 5 individual portions of pudding stacked upright. They also felt warm. The temperature in this air curtain refrigerator was 45 degrees Fahrenheit. The milk in this refrigerator was 50 degrees Fahrenheit. It should be noted that the standard refrigerator temperature is 40 degrees Fahrenheit and below.

c) On 9/2/14 it was observed in the kitchen freezer that a chunk of ice was on the floor. There was a lot of condensation on the door of the freezer and the plastic curtain at the door in the freezer was missing a panel.

d) An uncovered food weight scale was observed to be at the bottom of a counter.

e) A large bin was observed to have pans and lids in it.

f) Hand washing sinks were observed without a wastebasket for discarding paper towels.

g) A knife attached to a magnet on the wall was observed to have dried food attached to it.

h) Fire extinguisher signs were observed to be on 2 sides of a wall but there were no fire extinguisher below the signs.

i) Therapeutic menus were not posted in the kitchen.

j) An intercom with a black phone was encrusted with dried dirt film.

k) A plastic wastebasket with clean linen was observed next to two bins with dirty linen. Two wastebaskets had no pedal to open the lid. A third wastebasket contained dirty linen and miscellaneous items.

l) Oil was observed stored in a large metal container. The contained was under a counter. During the observation the Food Service Director stated that this oil would be placed back in its original container to be stored in the refrigerator and then discarded.

m) Garbage cans in the kitchen had no lid and were not in use.

n) Cleaning brushes were observed to be in the oven.

o) Tiles over the fryer were detached from the wall creating a potential environment for insects.

p) Pizza cutters were found stored in a bin that contained wet kitchen utensils. The pizza cutters have sharp blades and should be stored in a manner that makes them easily visible to the staff.

q) Three pot washing sinks had lines on the sink to indicate the amount of water to be used with detergent yet the sinks were not filled to the line.

r) A yellow bucket containing dirty water and a mop was observed stored in the kitchen between 2 refrigerators.

It was observed that foods were not labeled appropriately. Cooks and /or food service employees only labeled foods with one date. It should be noted that the standard of practice for food labeling is to identify the food item that has been opened or wrapped. The label should contain the date the item was opened or wrapped, and the date the food should be discarded. It was observed that pans of foods covered with aluminum foil were unlabeled. That then required staff to lift the foil on the pans in order to identify the food items. A large bottle of Italian dressing was open yet it had no date when it was opened. There was unlabeled sliced Swiss cheese and cold cuts on a rack, 4 racks with seasonings had no label on the containers that had been opened.

Standard food labeling such as identifying the food item, dating the food item when it's opened and dating the item when it expires were not followed.

A. Based on observation and staff interview, Mid-Hudson Valley Division of Westchester Medical Center failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.

The findings are:

1. On the morning of 8/19/2014 observation within the Kitchen revealed that there was a dust laden ceiling vent in the Chemical Room.

2. On the afternoon of 8/19/2014 on the 5th. Floor Mental Health Unit it was observed that there was a dust laden ceiling vent in the Dining Room.

3. On the morning of 8/29/2014 it was observed that one of the walls within the Mental Health Seclusion Room had two rectangular pieces of metal on them.

These findings were concurrently verified by Staff #1, the Senior Director of Support Services.

B. Based on observation and staff interview, Westchester Medical Center failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.

The findings are:

1. On the morning of 9/2/2014 observation within the Emergency Department revealed that:

a) in both Trauma Rooms #2 and #3 there was exposed cornerbead by the sink columns.

b) in Trauma Room #3 there were two unsealed holes in the walls.

c) in Trauma Room #3 the backsplash for the sink was not flush with the wall (i.e. it was damaged).

d) in Room 16 at the head of the bed there was a broken cover plate.

e) the outside wall of Isolation Room #15 had exposed cornerbead.

f) in the Pediatrics Exam Room #1 there was a dust laden ceiling vent.

g) in the Children's Waiting Room there were eight (8) torn chairs.

2. On the afternoon of 9/2/2014 observation within the Ambulatory Surgery Center revealed that:

a) in the vicinity of the handrail corner return adjacent to Room 1F24 there was a hole in the wall.

b) the Housekeeping Closet door was damaged and did not self latch.

c) in the Intake Pre-Ambulatory Bay #5 below the chair rail there were two dents in the wall.

d) the signage for the Supply Room and the Clean Storage Room were missing.

e) the Soiled Utility Room door hardware was damaged. Also the door latch was stuffed with paper.

f) the Janitor's Closet door did not self latch.

3. On the afternoon of 9/2/2014 observation within the Children's Hospital Radiology Department revealed that:

a) the Waiting Room had a damaged cover plate.

b) an MRI table had a torn mattress and a damaged table top.

c) in the Ultrasound Room there was a torn pad on a stool.

d) in the vicinity of the CT Scanner there was a loose red outlet cover.

e) there was a full bin of trash bags being stored in the Housekeeping Room, Room 1319.

4. On the morning of 9/3/2014 observation within the Children's Hospital Trauma Intensive Care Unit (TICU) revealed that:

a) a refrigerator located in TICU West had ice build-up in the freezer section.

b) in a Soiled Utility Room, Room 2319, there was a stained ceiling tile.

5. On the morning of 9/3/2014 observation within the Children's Hospital Trauma Neonatal Intensive Care Unit (NICU) revealed that:

a) the room signage for the Clean Storage Room, the Transition Room, the Locker Room, three of the Storage Rooms, etc was missing .

b) in the Waiting Room Bathroom the toilet bowl was loose/not flush with the wall.

c) In the Clean Utility Room there were two unsealed holes in a wall, and a hole in the wall that was patched with medical tape. Exposed metal cornerbead was also found in this room.

6. On the morning of 9/3/2014 observation within the Literature Unit revealed that the signage for the IT Closet was missing. There was also a dust laden ceiling vent found in this room.

7. On the afternoon of 9/3/2014 observation within the Radiology CT Scan Room revealed that there was exposed cornerbead by the handwash sink.

8. On the afternoon of 9/3/2014 observation within the Nuclear Medicine Suite revealed that:

a) inside the Reading Room there was a spot cooler duct that was sealed around a ceiling tile by duct tape.

b) the signage for the Electrical Closet was missing.

c) in the Resident Doctor's Documents Room there were at least twelve (12) boxes that were stored on the floor.

9. On the afternoon of 9/3/2014 observation within the Heart Institute revealed that:

a) in the Clean Storage Room there was a dust laden ceiling vent.

b) the signage for the Clean Storage Room and the Dirty Utility Room was missing.

10. On the morning of 9/4/2014 observation within the Pre-Admission Area revealed that:

a) in the main room there was a dust laden ceiling vent.

b) in Room B there was a phlebotomy chair that was torn/damaged.

c) in the hallway there was a bariatric phlebotomy chair that was torn/damaged.

11. On the morning of 9/4/2014 observation within the Medical Records Building revealed that:

a) in the File Room there was a stained ceiling tile. Another stained ceiling tile was found in the vicinity of the wheelchair lift.

b) in the File Room there were over twenty five (25) boxes being stored on the floor. This was found throughout the room.

c) in the Storage Room, within the File Room, there multiple boxes of equipment, etc. being stored on the floor.

12. On the afternoon of 9/4/2014 observation within the Pulmonary Suite revealed that the signage for the Bathroom and a doctor's private office was missing.

13. On the afternoon of 9/8/2014 observation revealed that within the Main Lab Storage Room there was a cracked/damaged wall.

14. On the afternoon of 9/8/2014 observation revealed that within the Dental Storage Room there was a cracked/damaged wall.

Findings 1 through 14 were concurrently verified by the Staff #3, the Director of Engineering and Maintenance.

15. On the morning of 9/2/2014 observation within the Kitchen Emergency Department revealed that:

a) some floor tiles at the entrance to the freezer were observed to be broken, which hinders proper cleaning and disinfection and presents a potential for infection.

b) The janitor closet in the kitchen did not have a light.

c) The ice machine in the kitchen was observed to have leak of water and needed repair.

16. On the morning of 9/2/2014, observation within the Endoscopy Suite revealed that:

a) it was noted the seams between the floor tiles had muddy black dirt.

b) the examination chair in procedure room #5 was observed to have a ripped surface.

c) the drain pipes underneath the hand-wash sink in the handicapped bathroom of the suite was not insulated or otherwise configured to prevent abrasion and or burn as per ADA requirement.

d) there were many broken floor tiles in the medical record and the dental corridors outside the dental waiting area and the burn unit area, which creates a tripping hazard and an infection control issue.

17. On the afternoon of 9/2/2014 observation within the Hyperbaric Unit revealed that the drain pipes underneath the hand-wash sink in the men and women bathrooms were found to lack insulation or otherwise be configured to prevent abrasion and or burn of the wheelchair users as per ADA requirement.

18. During tours of the various psychiatric units within the Behavioral Health Building on 9/3/2014, the following was observed and brought to the attention of the facility staff who was accompanying the state surveyor and who acknowledged the findings:

Psychiatric Unit - B3 Unit:
a) The handrails of the corridors were found to have gaps between them and the wall which is a potential looping hazard. This was observed in all the Psychiatric Units.

b) The hand-wash sink of patient bathroom 324 was found to have a goose neck faucet which is a potential looping hazard.

c) There were chipped paint on the walls and ceilings of many bathrooms and rooms of the psychiatric units. Examples included, but were not limited to: Room B326, Bathroom B328, bathroom 344

d) The door hinges of the seclusion room of unit B3 were of the regular type, which pose a potential looping hazard, rather than the piano hinge type.

e) The exit signs in the psychiatric units were found to have gaps between them and the ceiling tiles which is a potential looping hazard.

f) The laundry room of Psychiatric B3 unit was found to have a metal conduit above the room door with a gap between the conduit and the wall that is greater than 2 inches and that poses a looping risk.

g) The access door of the induction unit in room 362 was loose and was not secured.

h) The Gasket on the window of room 326 was detached and broken.

i) There was a door stop on the door to bathroom B364.

j) The light indicator of the nursing call outside room 329 was found to be broken (falling apart) and held to the wall by duct tape.

Adult Inpatient Psychiatric Unit (A2 Unit):
During a tour of the Unit at 11:30 AM on 9/3/2014, the following issues were identified in the presence of staff #4 who acknowledged the findings:

a) There was an electric conduit that extends from the floor to the ceiling next to the nursing station which the staff is calling "the Bar". It is a potential looping hazard.

b) There were different loose and light items on the surface of the Bar that created a potential safety risk as they could be used as a weapon or to harm others.

c) The phone on the nursing station had a very long cord that can be used self or other harms.

d) There were other items by the nurse station that could be used as a weapon or to harm self or others, such as, a chair with wheels, a heavy security monitor, and a coffee container.

e) The water fountain was found to have a metal faucet that is potential looping hazard. The Director of Nursing stated that that water fountain is not working and she was awaiting its removal from the unit.

f) The TV located mounted to the wall near to stairwell #2 was found to have a loose dangling cable cord which is a potential looping hazard.

g) The door hinges of the laundry room were the regular type, which pose a potential looping hazard, rather than the piano hinge type.

h) The exhaust vent of the Dining and Activity room #A231 had big holes that are a potential looping hazard.

i) The hinges of the door of room A231 were the regular type, which is a potential looping hazard.

Psychiatric Unit B2:
During a tour of the Psychiatric Unit B2, B1 and the children unit of the Behavioral Health Building on the afternoon of 9/3/2014, the following were identified in the presence of employee # 4 who was accompanying the state surveyor and acknowledged the findings:


a) The door hinges of the dining room are the regular type, not the piano hinge type that is required for the psychiatric units. This is a potential looping hazard.


b) There is a piano in the dining room which poses a potential looping hazard, particularly the legs of the piano.


c) The lounge room B226 was noted to have regular hinges which is a potential looping hazard.


d) The water fountain on this unit has a square shape and its faucet or spigot protrudes above the surface, both pose a potential looping hazard.


e) The exit signs of this unit were not flush mounted to the ceiling and had gaps between them and the ceiling which is a potential looping hazard.


f) There was data cable observed hanging above the central desk which is a potential looping hazard.


g) The fire alarm bell next to room B257 was noted to have a gap between it and the wall which is a potential looping hazard.


h) The exhaust vents of bathroom B258 and B264 were noted to have big openings that are approximately 1/4 of inch in diameter, which is a potential looping hazard.


Psychiatric Unit B1 (Adolescent Unit):
a) The Gasket of window of the dining room was observed to be coming off and in disrepair.

b) There were areas of the sheetrock wall that were broken in room B115.

c) The water fountain next to room B124 is a potential looping hazard.

d) There were big openings at the air supply vent of room B141 which is a potential looping hazard.

e) The air supply vent and some openings in the ceiling tiles of the corridor by room B146 are potential looping hazards.

f) There was a clean linen cart noted in the back area of the unit by room B153 and B159 which are safety and looping hazards.

g) There was no light in electric room B136 and the floor of this unit was noted to be dirty.

The Children Psychiatric Unit on the 1st Floor:
a) The electric room A112 was found to have dirty floor and no light.

b) There were 6 closets and or cabinets with Padlocks in room A129, in addition to door handles of the cabinets and the legs of a piano inside this room, all of which are potential looping hazard.

c) The induction unit and the exhaust vent of room A116, were observed to have hole which are potential looping hazard.

d) There was a clock mounted to the wall by room A118 which is potential looping hazard.

e) The water fountain and its faucet is a potential looping hazard.

f) There were one clean linen and two soiled linen hampers observed to be stored next to the water fountain. This is an infection control issue and looping risk.

g) The bell of the fire alarm was observed as being mounted to the wall with a gap between it and the wall which is a potential looping hazard.

h) The induction units in the corridor by room A141 and in the shower room were observed to have holes that are potential looping hazards.

i) The door of the shower room was found to have regular hinges, which is a potential looping hazard, rather than the piano hinges that are required for the psychiatric units.

19. On the morning of 9/4/2014, in the Operating Room Suite (OR) post-anesthesia care unit (PACU) in the Macy's building, it was observed that the push bar of the exit door next to Room 12 was broken.

20. On the morning of 9/5/2014 while in the Medical Intensive Care Unit observations identified the following:

a) The linen of the bed in room 5 was observed to be ribbed.

b) The audible alarm (indicator) of the airborne isolation room #216 of the MICU was not working properly. The door of the room was wide open, but the alarm did not sound.

21. On the morning of 9/9/2014 while in the Children Hospital and the South East Wing - 3rd floor of the Main Hospital, observations identified the following:

a) the Soiled Utility Room #372 was found to have a missing ceiling tile. The exhaust vent and the space or gap created by the missing tile were covered by plastic sheeting..

b) the exit door to stair #12 of the 3rd floor of the Children Hospital was found to be able to be opened by use of a push bar, rather than locked as indicated by a sign on the door that says: "This door is electronically locked and that an access card is required." During an interview of employee # 4, he/she acknowledged that this door unit should be secured and locked to prevent child and or infant abduction.

Findings 15 through 21 were concurrently verified by the Staff #4, the Senior Vice President of Facilities.

Based on observations and staff interviews, it was determined that the facility failed to meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 Edition.

Findings include:

A. During the survey of Mid-Hudson Valley Division of Westchester Medical Center from 8/19/2014 through 8/29/2014, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire/Life Safety Code K-Tags:

K17 (Corridors are separated from use areas by walls constructed with at least ½ hour fire resistance rating. 19.3.6.1, 19.3.6.2.1, 19.3.6.5)

K18 (Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3)

K25 (Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.)

K145 (The Type I EES is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.)


B. During the survey of Westchester Medical Center from 9/2/2014 - 9/9/2014, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire/Life Safety Code K-Tags:

K12 (Building construction type and height meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1)

K18 (Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3)

K29 (One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1)

K52 (A fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4)

K56 (The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system. 19.3.5)

K64 (Portable fire extinguishers are provided in all health care occupancies in accordance with 9.7.4.1. 19.3.5.6, NFPA 10)

K72 (Means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10)

K76 (Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities. (a) Oxygen storage locations of greater than 3,000 cubic feet (cu.ft). are enclosed by a one-hour separation.)

K141 (Non-smoking and no smoking signs in areas where oxygen is used or stored are in accordance with 19.3.2.4, NFPA 99, 8.6.4.2.)

K145 (The Type I EES is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.)

A. Based on observation, record review and staff interview, the Mid-Hudson Valley Division of Westchester Medical Center failed to develop a system for identifying and controlling inspections and communicable diseases of patients and personnel.

The findings include:

1. On the morning of 8/27/2014 observation within the Emergency Department identified that:

a) the Isolation Room #5 had neutral air flow to the hallway. This room is required to have negative air flow.

b) the Soiled Utility Room had positive airflow to the hallway. This room is required to have negative air flow.

2. On the morning of 8/28/2014 observation within the Central Sterile Area revealed that there was an unsealed gap between an outer metal flange and the top of the AMSCO 3043 Autoclave. This gap served as a pass through of dust, etc., into this clean room.

3. On the morning of 8/28/2014 record review of Mid-Hudson Regional Valley Division of Westchester Medical Center WMC OR Sheet readings from 7/22/2014 to 8/28/2014 and the Westchester Medical Center's Perioperative Humidity and Temperature Guidelines identified that:

a) The temperatures were above the allowable range for twenty four (24) out of the thirty seven 37 days that were requested. It should also be noted that on eight (8) out thirty seven (37) days (i.e. 8/3, 8/4, 8/5, 8/10, 8/11, 8/16, 8/17, and 8/24/2014) the operating rooms (ORs) were not recorded.

Although the temperature range on the OR Readings Sheet was 68 to 75 degrees Fahrenheit, the temperature range found within Westchester Medical Center's Perioperative Humidity and Temperature Guidelines was 68 to 73 degrees Fahrenheit. If this was considered the maximum allowable temperature as per hospital policy, then the facility was out of compliance for 31 out of 36 days.

The humidity levels for OR-6 were above the allowable range for twenty seven (27) out of thirty seven (37) days that was requested.

The facility did not provide any documentation verifying that the temperature and/or humidity was adjusted and retested before patient use. For example: Although the revised/current Mid-Hudson Valley Division of Westchester Medical Center Temperature/Humidity Log Sheet indicates that OR-1's temperature was turned down and rechecked after 1 hour, it was not clearly written on the log sheet. Furthermore, the reference of turning an OR temperature down to acceptable levels and then rechecking after one hour is not referenced in the Westchester Medical Center's Perioperative Humidity and Temperature Guidelines.

b) upon request the facility presented the Westchester Medical Center's Perioperative Humidity and Temperature Guidelines. When Westchester Medical Center took over St. Francis Hospital, policy/procedures specific to the newly established Mid-Hudson Valley Division of Westchester Medical Center should have been created.

c) Mid-Hudson Valley Division of Westchester Medical Center was not following its own policy. The policy states that "Temperature and Humidity should be recorded daily in all Operating Rooms and Sterile Supply Areas." As previously stated within this citation, eight (8) out thirty seven (37) days (i.e. 8/3, 8/4, 8/5, 8/10, 8/11, 8/16, 8/17, and 8/24/2014) the operating rooms (ORs) were not recorded.

This policy also states that "The temperature and humidity levels not monitored by Facilities will be recorded/logged by the individual units." For the eight (8) days in which the OR's were not recorded on the OR Readings Sheet, the facility could not produce evidence that the OR's temperature and humidity were recorded by an individual unit.

These findings were concurrently verified by the Staff #1, the Senior Director of Support Services.


B. Based on observation and staff interview, Westchester Medical Center failed to develop a system for identifying and controlling inspections and communicable diseases of patients and personnel.

The findings include:

1. On the morning of 9/2/2014 observation within the Emergency Department revealed that a Housekeeping Closet, Room 1251, had neutral air flow to the hallway. This room is required to have negative air flow.

2. On the morning of 9/2/2014 observation within the Ambulatory Surgery Center revealed that a Soiled Utility Room, Room 123, had positive air flow to the hallway. This room is required to have negative air flow.

3. On the morning of 9/3/2014 while in the Pediatric Intensive Care Unit Soiled Utility Room it was observed that access to the handwash sink was blocked by a container of miscellaneous equipment.

4. On the afternoon of 9/4/2014 while in the Pulmonary Suite it was observed that the freezer in the laboratory products refrigerator had a thick layer of ice build-up.

Findings 1 through 4 were concurrently verified by the Staff #3, the Director of Engineering and Maintenance.

5. On the morning of 9/2/2014 observation within the Endoscopy Suite revealed that:

a) the Clean Supply Room was observed to have a negative air flow instead of the required positive air flow for this type of room.
b) the Clean Supply Room next to the entrance of the Endoscopy Suite had negative air flow instead of the required positive air flow for this type of room.
6. On the afternoon of 9/2/2014 observation within the Burn Unit revealed that:
a) the Medication Room #31 was found to have a negative air flow instead of the required positive air flow for this type of room.
b) there was a scale stored in the patient bathroom which is a potential infection control issue.
7. On the afternoon of 9/2/2014 observation within the Operating Room Suite (OR) revealed that:

a) the Soiled Utility Room 209 was found to have positive air flow instead of the negative air flow that is required for this type of room.

b) the airborne isolation room #4 was found to have to no hand-wash sink, which is a potential hazard for spreading infections and cross contamination.

8. On the morning of 9/5/2014 observation within the Medical Intensive Care Unit (MICU) revealed that:

a) the Medication Room #216 was found to have a negative air pressure instead of the required positive air pressure for this type of room.

b) the Clean Work Room #215 was found to have a negative air pressure instead of the required positive air pressure for this type of room.

9. On the morning of 9/5/2014 observation within the Surgical Intensive Care Unit (ICU) Room #3 revealed that inside the patient bathroom there was a sharps container mounted on one of the walls and a soiled linen hamper being stored inside this room.

10. On the morning of 9/5/2014 observation within the Coronary Care Unit (CC) revealed that:

a) the Airborne Isolation Room #7 was found to have neutral air pressure instead of the required negative air pressure for this type of room.

b) the Patient room CCU2 was observed to have soiled linen hamper stored in the bathroom. There also were various items, including clean pillows being stored on shelves above the stool in the bathrooms of this unit. This is an infection control concern.

11. On the morning of 9/5/2014 observation within the Cardiothoracic Intensive Care Unit (CTICU) revealed that:

a) the Airborne Isolation Room CTCU 7 was found to have a neutral air pressure instead of the required negative air pressure for this type of room.

b) all the bathrooms of this unit and other ICU units (A, B, C and D) were noted to have no hand-washing sink in the bathrooms which is a potential for spreading of infections.

12. On the morning of 9/5/2014 observation within the Intensive Care Unit-D revealed that the Clean Utility Room of this unit was found to have negative air pressure instead of the required positive air pressure for this type of room.

13. On the morning of 9/9/2014 observation during a tour of the Children Hospital and the South East wing - 3rd floor of the Main Hospital revealed that room 377, the Medication Room, was found to have neutral air pressure instead of the required positive air pressure for this type of room.

Findings 5 through 13 were concurrently verified by the Staff #4, the Senior Vice President of Facilities.