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.

WESTCHESTER MEDICAL CENTER 100 WOODS RD VALHALLA, NY 10595 May 19, 2017
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on document review, interview and video surveillance review, it was determined the facility did not document in the central log a patient who had presented to its psychiatric ED seeking a psychiatric evaluation and care. (Patient #1).

Findings include:

Review of the facility's video surveillance camera of the hallway in the Behavioral Health Center (BHC) revealed that on 4/27/17 at 5:18:21 PM, Patient #1 wearing a white T-shirt and black pants and a female wearing a red and black jacket, entered the Psychiatric ED in the BHC. Patient #1 passed Staff B, Security Officer, who was seated at a desk and continued to walk down the hallway in the BHC while gesticulating with his hands. Staff C, Security Officer, came through double doors and stopped the patient. Staff B got up from his desk and walked towards the patient. Staff B turned back up the hallway and then they stopped. The side view of another female's head came into view and she appeared to be talking to Patient #1 who was talking and gesticulating with his hands. After approximately 2 minutes they disappeared from view in the video.

Staff B, a Security Officer who was seated at the security desk was interviewed on 5/19/17 at 9:50 AM. He stated on 4/27/17 when the patient came to him, he (interviewee) asked the patient to wait for 5 minutes because he was attending to another patient. Staff B stated when he finished with his patient he ascertained that Patient # 1 needed a psychiatric evaluation so he called into the PERC (Psychiatric Evaluation Referral Center) and told the staff there was a "walk in." They stated they would be out in a minute to check. Staff B further stated the patient became irate and began to talk loudly. He stated the patient said you "better come and help me" and he was "putting on a show". Staff B stated Staff E, Psychiatrist came to the patient and talked to the patient who calmed down. He further stated he did not hear the conversation between the doctor, the patient, and his escort. They left the building. They did not enter the PERC. He further explained walk-ins are seen in the waiting area by the physician and based on the physician's decision, the patients may be entered in the log.

Review of the Behavioral Health security log revealed the patient's name was not entered for his visit of 4/27/17. Review of the facility's central ED log revealed there was no documented evidence that the patient presented to the facility's BHC ED on 4/27/17.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on document review, interview and video surveillance review, it was determined a patient who presented to the Behavioral Health Center (BHC) ED did not receive an appropriate medical screening examination and was not provided an appropriate mode of transportation to the Main ED. This was evident in one (1) of 24 medical records reviewed. (Patient #1).

Findings include:

Review of the facility's video surveillance camera of the hallway in the BHC revealed that on 4/27/17 at 5:18:21 PM, Patient #1 wearing a white T-shirt and black pants and a female wearing a red and black jacket, entered the Psychiatric ED in the Behavioral Health Center (BHC). Patient #1 passed Staff B, Security Officer, who was seated at a desk and continued to walk down the hallway in the BHC while gesticulating with his hands. Staff C, Security Officer, came through double doors and stopped the patient. Staff B got up from his desk and walked towards the patient. Staff B turned back up the hallway and then they stopped. The side view of another female's head came into view and she appeared to be talking to Patient #1 who was talking and gesticulating with his hands. After approximately 2 minutes they disappeared from view in the video.

Staff B, a Security Officer who was seated at the security desk was interviewed on 5/19/17 at 9:50 AM. He stated on 4/27/17 when the patient came to him, he (interviewee) asked the patient to wait for 5 minutes because he was attending to another patient. Staff B stated when he finished with his patient he ascertained that Patient # 1 needed a psychiatric evaluation so he called into the PERC (Psychiatric Evaluation Referral Center) and told the staff there was a "walk in." They stated they would be out in a minute to check. Staff B further stated the patient became irate and began to talk loudly. He stated the patient said you "better come and help me" and he was "putting on a show". Staff B stated Staff E, Psychiatrist, came to the patient and talked to the patient who calmed down. He further stated he did not hear the conversation between the doctor, the patient and his escort. They left the building. They did not enter the PERC. He further explained walk-ins are seen in the waiting area by the physician and based on the physician's decision the patients may be entered in the log

During interview with Staff E, psychiatrist, stated on 5/19/17 at 10:05 AM that while she was attending to another patient in the Psychiatric ED, she heard a loud noise in the hallway. She stated that she left that patient and went to the hallway where she encountered Patient #1. She further stated that she spoke to Patient #1 and concluded that "he was under the influence" and that he did not have suicidal or homicidal ideation. Staff B also stated that she directed the patient to go to the Main ED which is located in another building on the premises. Staff E stated she documented her assessment of the patient and the surveyors requested a copy of the assessment. When she was asked what is the policy for transporting patients to the main ED, Staff E stated that ambulance transport the patients to the Main ED.

Staff G, Director of Nursing, Behavioral Health stated on 5/19/17 at 2:00 PM that Staff E could not recall if she did or did not document the Patient's #1 assessment.

There was no documented evidence to confirm that Staff E conducted a medical screening examination to rule out if an emergency medical condition existed.

The facility's policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" which was last revised 7/14/16 states that "every patient who comes to the Emergency Department for examination or treatment will be given an appropriate medical screening examination to determine whether an emergency medical condition exists."

These findings were discussed with Staff F, the Director, Quality and Safety during an interview which was conducted on 5/19/17 at 3:30 PM.
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation, document review and interview, it was determined the facility had not posted in the main entrance, waiting areas, and treatment areas, signs specifying the rights of individuals under section 1868 of the Act with respect to examination and treatment for emergency medical conditions and women in labor and information indicating whether or not the hospital participates in the Medicaid program (EMTALA signs).

Findings include:

A tour of the facility conducted on 5/16/17 at 10:15 AM revealed the facility had not posted the EMTALA signs at the main entrance or waiting area in these locations.

During an interview with Staff A, a Security Officer who was posted at this location at the time of the observation, he stated that sometimes visitors to the hospital enter the facility through the main entrance to seek emergency care in the emergency department (ED).

A tour of the treatment areas in the main ED at 11:10 AM on 5/16/17 revealed there was no EMTALA sign in these locations.

The facility's policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" which was last revised 7/14/16 states that a sign will be conspicuously posted in the Emergency Department. This policy does not meet the requirement for this regulation.