The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NYACK HOSPITAL 160 NORTH MIDLAND AVENUE NYACK, NY 10960 Aug. 4, 2017
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on document review and interview, it was determined the facility did not provide a written response to patient's grievance in a timely manner. This was evident in one (1) of six (6) grievances reviewed.

Findings include:


Grievance #1 was received on 1/16/17: Complainant alleged that he did not receive the appropriate medication dose for his Parkinson's Disease and that it affected his ability to participate in physical therapy.

The facility sent out a letter to the complainant on 2/8/2017.

The facility policy titled "Patient Complaint -Grievance Process," last revision 3/16 states: the facility must provide "an initial written response within 7 days of a grievance."

These findings were discussed on 8/4/17 at 11:45 AM with Staff A, Manager of Patience Experience.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of documents and interview, it was determined the facility failed to: (a) provide written notices of its decision, (b) failed to disclose the steps taken on the behalf of the patient to conduct the investigations, (c) failed to inform the complainant of the results and (d) failed to provide the date of completion of their investigations. This was identified in five (5) of six (6) grievances reviewed.

Findings include:

Review of Grievances and Complaints for January 2017 to March 2017 identified:

Grievance #1 was received on 1/16/17. Complainant alleged that he did not receive the appropriate medication dose for his Parkinson's Disease and that it affected his ability to participate in physical therapy.
The facility sent out a letter to the complainant on 2/8/2017. The letter failed to address the steps taken to complete the investigation, the result of the investigation and the date of completion.

Grievance #2 was received on 2/12/17. Complainant alleged: she was over-medicated, that the nursing staff kept taking her blood pressure on the arm that was receiving the intravenous fluids, no one would answer her call bell, therefore she had an accident in the bed. In addition, she stated that the staff did not discuss the change in her medication regime.

The facility's written response failed to provide the results of the investigation and the date of completion of the investigation.

Grievance #3 was received on 2/23/27. Complainant alleged that in the middle of the night she yelled out because she was experiencing paralysis and was unable to speak. The patient reported that her blood sugar was low and a rapid response was called and that it led to her medical decline.

The facility's written response failed to provide the results of the investigation and the date of completion of the investigation.

Similar findings were noted for Grievance #4 and #5.

These findings were discussed on 8/4/17 at 11:45 AM with Staff A, Manager of Patient Experience.

The facility policy titled "Patient Complaint -Grievance Process," last revised 3/16 states:
"In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."