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 Nov. 12, 2020
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on medical record review, document review and staff interview, in one (1) of four (4) medical records reviewed, the facility failed to ensure the written notice of response to a patient/representative's grievance addressed their complaint regarding patient abuse (Patient #1).

Findings include:

Review of medical record for Patient #1 identified an [AGE]-year-old Spanish speaking individual who was admitted on [DATE] with multiple medical conditions.

On 10/18/19, the patient reported an incident through interpretive services, he stated "I want you to know they are hitting me, they are hitting me all over my face and they shouldn't do that," patient was sobbing. "I can't go to the bathroom to pee because it is forbidden, I can't go to the bathroom to poo because it is forbidden."

Facility documents showed that an investigation of the incident was initiated on 10/21/19 and completed on 10/22/19.

Review of the facility's final written notice of its decision to the patient representative on 12/20/19 revealed the investigation and result of the allegation of assault were not included.

This finding was brought to the attention of Staff A, Director of Quality and Patient Safety on 11/09/20 at approximately 2:45 PM.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review, and staff interview, in one (1) of four (4) medical records reviewed, the facility failed to ensure that allegations of inadequate nursing care and an incident of abuse was timely and thoroughly investigated (Patient #1).

Findings include:

The facility policy and procedure titled: "Patients Complaint and Grievances," last revised 11/2020 states, "Hospital must review, investigate and resolve each patient's grievance within a reasonable time frame; on average the expectation would be a written response of resolution within 7 days. However, if a grievance is complicated and requires extensive investigation and cannot be completed within 7 days, the hospital shall inform the patient's representative by seven days that the hospital is still working to resolve the grievance."

Review of medical record for Patient #1 identified an [AGE]-year-old Spanish speaking individual who was admitted on [DATE] with multiple medical conditions.

On 10/18/19, the patient reported an incident through interpretive services, he stated "I want you to know they are hitting me, they are hitting me all over my face and they shouldn't do that," patient was sobbing. "I can't go to the bathroom to pee because it is forbidden, I can't go to the bathroom to poo because it is forbidden."

Documentation of the incident in the medical record on 10/18/2019 indicated the patient was trying to get out of bed without an assistant. The sitter attempted to stop him, the sitter accused the patient of pushing him against the wall and the patient accused the sitter of slapping him across the face.

During an interview on 11/09/2020 at 12:00 PM, Staff E, Charge Nurse, stated that he became aware of the incident on the date it happened, however he cannot remember whether he spoke with the patient or a Supervisor about the allegations.

During an interview on 11/9/2020 at 12:15PM, Staff D, the patient's assigned nurse stated that he was in another patient's room at the time of the incident. He did not talk with the patient about the allegations because he believed the patient was confused. He does not recall talking to the Sitter (Patient Care Assistant) about the incident.

During an interview on 11/9/2020 at 11:45AM, Staff J, RN, stated that on 10/18/2019 she heard yelling and observed the incident from the nursing station. Patient #1 walked out of his room, he was very agitated and was complaining about Staff G, a sitter. Staff G (Sitter), told her that the patient was trying to get out bed and he was trying to prevent him from doing so. The Sitter did not say he was hit by the patient. The patient's assigned nurse was not present during the incident, she informed him of what she observed.

Facility documents showed that an investigation of the incident was initiated on 10/21/19, three days post incident when the patient's daughter made a complaint via a phone call. A written complaint by the patient's daughter dated 10/21/19 was marked received on 10/31/20. The facility completed the investigation on 10/22/19 and indicated the allegations of staff to patient assault was unsubstantiated.

The facility investigation lacked interviews with the patient and pertinent staff members to obtain additional information about the identity of staff members that were involved in the alleged abuse and how often the incident had occurred in the past. In addition, the investigation did not immediately address the patient's nursing care complaints regarding bathroom privileges.

There was no documented evidence the facility implemented its grievance policy to promptly resolve a patient's grievance within an average of 7 days or informed the patient's representative by the seventh day that the facility is still working to resolve the grievance.

The facility's first written acknowledgement of the grievance was dated 11/11/2019, twelve (12) days after the complaint was received. The written response to the complaint was dated 12/20/19; over two months from the date the grievance was documented.

This finding regarding lack of documentation of a timely thorough investigation was brought to the attention of Staff A, Director of Quality and Patient Safety on 11/09/20 at approximately 2:45 PM.
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