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 Oct. 13, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on medical record review, document review and interview, in one (1) of six (6) medical records reviewed, it was determined the facility failed to ensure that (a) staff utilized less restrictive measures to manage an agitated patient, (b) staff documented justification for administering a mixture of medications for severe agitation and (c) the medical staff did not reassess the patient prior to ordering each dose of medications. This was evident for Patient #1.

Findings include:

(a) A patient was given a mixture of medication to calm the patient prior to utilizing other least restrictive measures.

See tag A 164.

(b) The staff did not document justification for ordering and for administering the mixture of medications to a patient
on multiple occasions.

See tag A 164.

(c) A patient was given a mixture of medications on multiple occasions, without a physician re-assessing the patient.

See tag at A 049.

These failures may have placed the patient at risk for harm.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, in one (1) of six (6) medical records reviewed, it was determined the medical staff failed to conduct and document reassessments of a patient who was given 5 (five) doses of a combination of Ativan (sedative), Haldol (antipsychotic) and Benadryl (antihistamine). This was evident for Patient #1.



Findings include:

Review of Patient #1's medical record identified the following: police officers brought this thirty - eight year old patient to the emergency department (ED) on 4/18/17 at 12:26 PM because she had set fire to a mattress in her residence and had threatened to burn down the facility. The psychiatrist "Report of Consultation" indicated that upon arrival the patient was extremely agitated, delusional, belligerent and making threatening statements. The patient had a long psychiatric history of Schizoaffective Disorder, Bipolar type, Borderline Personality and Post Traumatic Stress Disorder, and his treatment plan was for hospitalization of the patient.

The psychiatrist ordered Benadryl 50 milligrams (mg) intramuscularly (IM), Haldol 5 mg IM and Ativan 2 mg IM and the nurse gave the medications at 1:02 PM.

The psychiatrist ordered the following medications:
Haloperidol Lactate (Haldol) 5 mg IM Once One, 4/18/43 21:31 (9:31 PM).
Diphenhydramine HCL (Benadryl) 50 mg orally (PO) Once One, 4/18/17 21:33 (9:33 PM).
Haloperidol Lactate (Haldol) 5 mg PO Once One, 4/18/17 21:35 (9:35 PM).
Lorazepam (Ativan) 2 mg IM Once One, 4/18/17 21:36 (9:36 PM).

There was no documentation in the medical record that a member of the medical staff reassessed the patient prior to ordering these medications and there was no documentation to justify the administration of these medications.

Nursing documentation on 4/19/17 at 7:00 AM, revealed the patient was "sleeping soundly" and she had slept throughout the night.
Nursing documentation on 4/19/17 at 11:51 AM revealed the patient "continues to sleep soundly. The patient would not rouse for either breakfast or lunch tray".

At 7:13 AM on 4/20/17 nursing documentation noted the patient was in behavioral control, she was irritable and that she can be intrusive. At 4:26 PM, the patient continues to pace in an agitated state and she was offered medications to help her relax. A psychiatrist ordered the combination of Benadryl 50 mg IM, Haldol 10 mg IM and Ativan 3 mg IM and the nurse gave the patient these medications at 4:26 PM.

There was no documentation in the medical record that a member of the medical staff reassessed the patient prior to ordering these medications and there was no documentation to justify the increased doses of Haldol and Ativan that were administered at 4:26 PM.

A psychiatrist ordered on [DATE] a combination of Benadryl 50 mg PO, Ativan 2 mg PO and Haldol 5 mg PO and a nurse gave the patient the medications at 10:36 AM.

There was no documentation in the medical record that a member of the medical staff reassessed the patient prior to ordering these medications and there was no documentation to justify the administration of these medications.

Nursing documentation revealed the patient was transferred to another hospital on [DATE] at 3:21 PM.

There was no documentation that a physician reassessed the patient throughout her more than 3 days stay in the ED.

During an interview on 9/26/17 at 2:30 PM, Staff A, the Director of Psychiatry stated that it is the facility's practice to reassess patients in the ED at least once per day.

The facility's "Rule and Regulations of the Medical Staff" states the medical record must contain "any observations relevant to care, treatment and services." It also states "progress notes shall be recorded in the patient's medical record at the time of observation, sufficient to permit continuity of care."

The facility does not have a policy that directs the staff for the management of agitated patients with the use of this combination of drugs.

This finding was shared with Staff D, the Director of Quality and Safety at 4:30 PM on 9/29/17.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on medical record review, document review and interview, it was determined the staff failed to use the least restrictive measures for an agitated patient before administering medications. This was evident in one (1) of 6 medical records reviewed (Patient #1).

This failure may have placed the patient at risk for harm.

Findings include:

Review of the medical record for Patient #1 revealed: the police brought the patient to the ED on 4/18/17 at 12:26 PM because she had set fire to a mattress in her residence and threatened to burn down the facility. The psychiatrist "Report of Consultation" documented that upon arrival the patient was extremely agitated, delusional, belligerent and making threatening statements. The psychiatrist ordered a combination of Benadryl (antihistamine) 50 mg, Haldol (antipsychotic) 5 mg and Ativan (sedative) 2 mg and they were all given intramuscularly (IM) at 1:02 PM.
There was no documentation in the medical record to indicate that less restrictive measures were implemented prior to administering these medications.

The psychiatrist ordered the following medications:
Haloperidol Lactate (Haldol) 5 mg IM Once One, 4/18/43 21:31 (9:31 PM).
Diphenhydramine HCL (Benadryl) 50 mg orally (PO) Once One, 4/18/17 21:33 (9:33 PM).
Haloperidol Lactate (Haldol) 5 mg PO Once One, 4/18/17 21:35 (9:35 PM).
Lorazepam (Ativan) 2 mg IM Once One, 4/18/17 21:36 (9:36 PM).

Nursing documentation on 4/19/17 at 7:00 AM, revealed the patient was "sleeping soundly" and she had slept throughout the night. On 4/19/17 at 11:51 AM, nursing documentation noted the patient "continues to sleep soundly. The patient would not rouse for either breakfast or lunch tray."

Nursing documentation on 4/20/17 at 4:26 PM revealed the patient continues to pace in an agitated state and she was offered medications to help her relax. A psychiatrist ordered a combination of Benadryl 50 mg IM, Haldol 10 mg IM and Ativan 3 mg IM on 4/20/17 and it was given to the patient at 4:26 PM that day.

There was no documentation in the medical record to justify the increased doses of Haldol and Ativan that were administered.

On 4/21/17, a psychiatrist ordered a combination of Benadryl 50 mg PO, Ativan 2 mg PO and Haldol 5 mg PO and it was given to the patient at 10:36 AM that day.

There was no documentation in the medical record to justify the administration of this combination.

There was no documentation in the medical record to indicate that less restrictive measures were implemented prior to administering these combinations of medications.

Staff A, the Director of Psychiatry stated during an interview conducted on 9/26/17 at 2:30 PM, that the combination of Benadryl, Ativan and Haldol is given for "severe agitation and emergencies." Staff A also stated that the combination of medication administered is not a chemical restraint.

The policy titled "Restraint and Seclusion" which was last revised 2/2017 states the staff should consider less restrictive alternatives such as verbal calming and de-escalation, offer fluids and nutrition, decrease stimulation, re-direction and teaching and diversional activities before using restraints.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review and interview, the facility did not track, and analyze all patient grievances and incidents in the Emergency Department (ED).


Findings include:

Review of the ED Complaints/Grievances log for 01/01/17 to 9/25/17 showed 52 complaints/grievances.
Ten (10) of 52 complaints/grievances reviewed by the surveyor showed no evidence of an investigation.

There was no evidence that these complaints/grievances were analyzed to determine trends and areas for improvement.

The policy titled "Patient Complaints and Grievances", last revised 11/2016, states "all complaints and grievances, actions taken and responses will be documented and reports will be distributed to Grievance Committee periodically for performance improvement purposes."

Review of the facility "Risk Events" reports from January 2017 to August 2017 for the ED psychiatric area (BRINN), showed a total of 11 incidents.
Three (3) of 11 were patients attempted suicide while they were been monitored in the BRINN.
One (1) of 11 had a head injury, was discharged home and "came immediately back to the ED."
Three (3) of 11 were allegations of patient "assaulted" by Security Officers.

There was no documented evidence that the hospital evaluated these incidents to determine the impact on patient care and to identify areas for improvement.

The facility had no documented evidence of analysis or discussion of these incidents in the ED Quality Assessment and Performance Improvement (QAPI) minutes.

During interview on 9/28/17 at 11:00 AM, Staff E, the Director of Quality confirmed the findings.

The policy titled "Occurrence/Serious Safety Event/Safety Catch Reporting", last revised 8/2017, states "occurrences will be reviewed, investigated and documented by the appropriate designee and all serious safety events should be immediately communicated to the Risk Management Department and/or Safety Department Administrative Leadership."
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on document review and interview, the facility did not use the data it collected to identify opportunities to improve the quality of care in the Emergency Department (ED).


Findings Include:

Review of the facility's Emergency Department QAPI program documented numerical breakdown of the following indicators:
-Re-admission in the Behavioral Health Services.
-Patient in restraints and seclusion.
-Unscheduled 72 hours returns.
-Code gray, (behavioral emergencies).
-Risk Events/Adverse Events
-Elopements
There was no evidence of review or analysis of the data.

During interview on 9/29/17 at 11:00 AM, Staff D, the Director of Quality and Safety confirmed the findings.

The Facility's "Performance Improvement and Patient Safety Plan" for 2017-2018, states: the focus of the program is to assess the way care is delivered, prioritizing areas for improvement and improve services.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, in four (3) of eight (8) medical records reviewed, it was determined the facility failed to ensure that staff conducted suicide screenings. (Patients # 3, 4 and 5).

Findings include:

Review of the policy titled "Suicide Risk Assessment" which was last revised 4/15 states "all patients presenting with a primary diagnosis or complaint of an emotional or behavioral disorder must be screened for their risk of suicide."

Review of patient #5's medical record identified the following: this is a thirty-eight year old patient who (MDS) dated [DATE] at 7:39 PM with a complaint of "high anxiety and suicidal thoughts." The social worker's documentation of 8/10/17 at 3:57 PM revealed the patient "made her first suicide attempt at [AGE] and has made numerous attempts since that time."
The ED nurse did not document and complete a SAD PERSON suicide screen according to the facility's policy.

Review of patient #3's medical record identified the following: this is a fifty-seven year old patient who (MDS) dated [DATE] at 8:56 PM with alcohol intoxication and suicidal ideation. The ED physician documented that the patient drank an excessive amount of whiskey and drank cough syrup. The patient also self-administered 2 Klonopin tablets and stated that she wanted to kill herself as well as to escape from life because of a recent loss of her job. The medical record revealed the patient had a vague plan.
There is no documented evidence in the medical record that A SAD PERSON suicide screen was not done.

Similar finding was noted for patient #4 who presented with behavioral disorder and the SAD PERSON suicide screen was not completed.

These findings were shared with Staff D, the Director of Quality and Safety on 10/13/17 at 2:30 PM.