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.

MONTEFIORE MEDICAL CENTER 111 EAST 210TH STREET BRONX, NY 10467 Jan. 22, 2021
VIOLATION: PATIENT RIGHTS: GRIEVANCE PROCEDURES Tag No: A0121
.
Based on medical record review, document review and interview, in one (1) of (6) complaints reviewed, the facility failed to implement its procedure for submission of a verbal grievance for investigation and resolution (Patient #1).

Findings include:

Review of "Patient Complaint and Grievance" policy (revised on 01/18) notes "complaint or grievance is entered into a centralized intake system and assigned a File ID#. Grievances are acknowledged by writing or personal contact, and the grievance process and timeline are explained to the griever in the acknowledgment. Responsible complaint 'responder' is designated and notified if it is not a Customer Service Department Associate, for investigation and follow up.

Review of medical record for Patient #1 revealed that on 09/29/2020 at 4:40 PM Staff Y, Social Worker noted that the patient reported he was sexually harassed by Staff X. The patient was evaluated by a Physician Assistant at 6:20 PM who noted that the patient complained he was touched inappropriately by Staff X.

Review of security occurrence report dated 9/29/20 at 6:20 PM, noted security staff was called to interview a patient alleging sexual abuse by a hospital staff.

Review of the facility's complaint log revealed the complaint of sexual assault made by Patient #1 was not entered into a centralized intake system and assigned a file ID number as per the facility's Complaint and grievance procedures.

On 01/15/2021, at 01:09 pm, during an interview with Staff U (Director of Patient Experience) she stated that on 09/24/2020 patient informed her of the sexual assault, and she referred the patient's complaint to Risk Management for investigation. Staff U reported that the patient called her several times inquiring about the status of his complaint.

On 01/15/2021, at approximately 01:30 pm, during an interview with Staff V (AVP of Operations) she acknowledged findings and reported that the complaint was referred to Risk Management and not to Customer Services whose responsibility was to implement the complaint and grievance policy.
.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
.
Based on medical record review, document review and interview, in one (1) of (6) complaints reviewed, the facility failed to implement its procedure for investigation and resolution of complaints and grievances (Patient #1).

Findings include:

Review of "Patient Complaint and Grievance" policy (revised on 01/18) notes ... Grievance investigations will conclude within five (5) calendar days, and the results of the investigation will be communicated to the grievance in-person, by telephone, e mail or letter by seven (7) calendar days. If a grievance is so complicated that it requires an extensive investigation and cannot be resolved within 5 calendar days, the hospital will inform the patient or the patient representative in writing, by e mail or telephone that the hospital is still working to resolve the grievance and will follow up within 20 days. If the communication of the investigation results is by telephone, the griever will be informed that a formal 'closing' letter will be sent in a timely manner. The grievance file will be closed when the closing letter is mailed to the griever."

Review of medical record for Patient #1 revealed that on 09/29/2020 at 4:40 PM, Staff Y (Social Worker) noted that the patient reported he was sexually harassed by Staff X. The patient was evaluated by a Physician Assistant at 6:20 PM who noted that the patient complained he was touched inappropriately by Staff X.

Review of security occurrence report dated 9/29/20 at 6:20 PM, noted security staff was called to interview a patient alleging sexual abuse by a hospital staff.

On 01/15/2021, at 01:09 pm, during an interview with Staff U (Director of Patient Experience) she stated that on 09/24/2020 patient informed her of the sexual assault, and the complaint was referred to Risk Management for investigation. Staff U reported that the patient called her several times inquiring about the status of his complaint.

Review of documents revealed that Labor Relations conducted an internal investigation of Staff X which resulted in the termination of his employment. However, there was no documented evidence that Customer Service received and investigated the complaint and a formal closing letter was sent to the complainant as per the facility's policy and procedures.

On 01/15/2021, at approximately 01:30 pm, during an interview with Staff V (AVP of Operations) she acknowledged findings and reported that the complaint was not referred to Customer Services who would have acknowledged the complaint, conduct an investigation and send a final letter to the patient.