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 Sept. 4, 2015
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, in three (3) of three (3) complaints reviewed, the Hospital did not ensure that complaints were investigated.

This lapse does not ensure that all patients will have their complaints investigated.


Findings include:

Review of the complaint log for the time period of 1/2/15 - 8 /27/2015 conducted on 9/3/15 identified:

Complaint #1 dated 6/29/15, revealed that the hospital received the complaint from an individual stating that her daughter and grandchild were taken to the emergency room after they were rear ended in a motor vehicle accident. The complainant alleged that the supervising nurse came to the waiting room and began saying very specific information about the patient, and that this was a HIPPA violation.

Complaint #2 dated 6/19/15, revealed that the hospital received the complaint which alleged that a patient's blood pressure was taken in the emergency room 's waiting area. The complainant alleged that the patient's HIPPA rights were violated.

Complaint #3, revealed that the hospital received a telephone call on 4/30/15, from the patient's wife who alleged that that there was a HIPPA violation. The complainant alleged that the hospital informed another individual that the patient's husband had a diagnosis of [DIAGNOSES REDACTED]

An interview with Staff #4 (Social Worker), was conducted on 9/3/15 at 12:20 p.m. Staff #4 stated that she is responsible to review patients' complaints. When she was queried by the surveyor as to how the complaints are investigated, she stated that the complaints are forwarded to the Manager of each department for investigation. Staff #4 related that she had no documentation from the Managers that the complaints were investigated.

The Hospital's Policy and Procedure titled "Patient Complaints and Grievances" stated "All grievances will be investigated as assigned by the VP of the appropriate area (s)."

Hospital staff failed to follow this policy and the above complaints were not investigated.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on document review and staff interview, the Hospital failed to provide for personal privacy when interviewing patients in the emergency room .
This puts the privacy of all patients at risk.

Findings include:

An observation of the emergency room s' Patient Registration was made on 9/2/15 at 10:50 a.m.

The Patient Registration area was constructed so that verbal interactions by the staff and patients could be heard by the Security Guard and other patients in the waiting room. The Patient Registration Area was located within 4 feet of the Security Guard and located approximately 10 feet from the Patients' Waiting Area. There was no observable sound proof barriers located between any of the aforementioned areas.

On 9/3/15, Staff #12 (Director of Nursing for the emergency room ) was interviewed. Staff#12 acknowledged that the Patients' Registration Area in the emergency room was not an "optional area" to conduct patient interviews.

There was no evidence that the Hospital ensured that the patient's Health Information was protected during interview.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and interview, the Hospital failed to ensure the comfort and safety of all patients.

Findings include:

The "Brinn"/ emergency room 's Behavioral Health Unit was toured on 9/2/15 at 11:20 a.m. The temperature in the room was noted to be excessively warm. The warm temperature was brought to the attention of Staff #15 (Charge Nurse). Staff #15 stated that the rooms are located above the heating station of the Hospital. She related that she did not know the temperature of the area, since there was no thermometer or thermostat located there.

The State Surveyor requested that the Hospital take the ambient temperature of rooms #4 and #10 in the Brinn and Staff #14 (Senior Director of Support Services) used a hand held device to check the rooms' ambient temperatures. The Temperature in room #4 was recorded as 88 degree Fahrenheit, while room #10 had temperature of 93 degrees Fahrenheit (the design temperature for inpatient area should be 70 -75 degree Fahrenheit).

Employee #14 informed the State Surveyor that one of the "Air handlers" for that area was broken.

On 9/3/15, the State Surveyors were provided with a written document that the facility's contracting company was notified of the problem. The document stated that the facility's "Variable Air Volume " was not working and that it needed to be replaced.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, the Hospital did not ensure that all patient in the Behavioral Health Unit were monitored continuously while they were in restraints. This was noted in one (1) of two (2) relevant records reviewed for patients in restraints.
This lapse in patient monitoring has the potential to put the safety of all patients at risk.
Findings include:

A review of MR #8 revealed that the patient was a [AGE] year old female who was brought to the emergency room on [DATE] at 10:30 p.m. by the local police. The patient was described by the police as "verbally challenging and causing a disturbance."

Review of the Physician's order on 8/14/15 at 1:50 a.m., noted that the Physician wrote an order for 4 point restraints for a duration of 2 hours. The justification for the restraint was agitation and physically threatening behavior.

The patient's medical record lacked evidence that the Nurse monitored this patient's condition while the patient was in restraints.

The medical record contained a copy of a "Monitoring Sheet" for "Restraint/Seclusion for Violent Self-Destructive Behavior," dated 8/14/15. This sheet had no documentation of continuous/ongoing monitoring while the restraints were applied. There was no documentation in the monitoring sheet to designate when the restraints were applied or when they were removed. The Nurses' Progress Note dated 8/14/15 at 2:20 a.m., stated "patient taken out of restraints at 0215 and went to bed."

During an interview with Staff #6, the Director of Nursing in the Behavioral Health Unit, acknowledged that the Monitoring Sheet dated 8/14/15 lacked documentation that the Nurse monitored the patient's condition "every 30 minutes" as required by the Hospital's Policy and Procedure titled "Restraint and Seclusion Manual, revised July 2015 and April 2015.

This Policy and Procedure stated that each restraint requires a new monitoring tool. All patients in restrains should be observed and assessed every 30 minutes for proper application, comfort, safety, respirations and circulation.