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WESTCHESTER MEDICAL CENTER 100 WOODS RD VALHALLA, NY 10595 April 16, 2018
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on document review and staff interview, it was determined the facility did not follow it's policy on how to inform the patient if a grievance will not be resolved, or if the investigation will not be completed within 7 days. The finding was evident in six (6) of six (6) grievance files reviewed.

Findings include:

Review of hospital policy, "Patient Complaints and Grievance," notes under procedure (3): "A written response is required of the grievance (which may or may not include resolution) within 7 days. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital shall inform the patient that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within 30 days or less."


Review of grievance files identified the following:

Grievance #1 arrived on 3/7/18 concerning a mother's grievance on the poor treatment her 9-year-old child received during his visit at the hospital. An acknowledgement letter was mailed to the complainant on 3/8/18 informing her of the receipt of her grievance and that the hospital will follow up with an investigation of her complaints.
A final letter containing the facility's investigation was sent to the complainant on 3/27/18, 20 days after the grievance was received.
The complainant was not informed that the facility was still working on the investigation of her grievance after 7 days, and given a timeframe within which a written response would be provided.

Grievance #2 arrived on 9/7/17 and an acknowledgement letter was sent to the complainant on 9/7/17. The final letter containing the facility's investigation was sent to the complainant on 9/22/17.
The complainant was not informed in writing that the facility was still working on the investigation of her grievance after 7 days, and given a time frame within which a written response would be provided.

Grievance #3 arrived on 8/24/17. An acknowledgement letter with an investigation of the complainant grievance, was sent by the facility on 10/17/17, 54 days after the grievance was received.
The facility did not follow it's policy to inform the patient if the grievance will not be resolved, or if the investigation will not be completed within 7 days. The patient was not given a timeframe within which a response would be provided.

Similar findings were identified in Files #4, #5, #6.


The facility's policy does not ensure an attempt by the facility to resolve all grievances in a timely manner.


The findings were acknowledged by Staff E, Service Excellence Officer, at time of the review.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, in one (1) of 12 medical records reviewed, it was determined the facility failed to develop a policy for the management of inpatients with allegation of sexual assault/abuse. This was evident for Patient #1.

Findings include:

Review of Patient's # 1 medical record identified the following: the patient was admitted to the facility on [DATE] with a diagnosis of Epidural (spinal) Abscess. A physician documented he was notified on 3/22/18, that the patient reported inappropriate touching by a male nurse the prior night during cleaning. This allegation was reported to a 4th year medical student.

During an interview on 4/12/18 at 2:07 PM, Staff A, 4th year medical student stated that on 3/22/18 during rounds, when asked about her night, the patient stated Staff B, RN, touched her vaginal area. Staff A stated she asked the patient if it was sexual abuse and the patient said yes. Staff A stated that she reported the allegation to Staff C, attending physician that day.

Review of the facility's policy titled "Management of Patients Presenting with Concerns For Sexual Abuse or Assault," last reviewed 4/2017, revealed the policy outlines the triage, intake and management of patients upon arrival to the emergency department when they disclose allegations of sexual assault/abuse. This policy includes an assessment and referral to a Forensic Acute Care Team (FACT) Examiner.

The policy does not address management of inpatients allegations of sexual assault/abuse.
There was no evidence that this policy was implemented for this inpatient who had a disclosed allegation of sexual abuse.

These findings were shared with Staff D, Director of Quality and Safety on 4/16/18 at 3:30 PM.