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.

NORTHERN WESTCHESTER HOSPITAL 400 EAST MAIN STREET MOUNT KISCO, NY 10549 Sept. 30, 2016
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, review of documents and interview, in one (1) of three (3) patients ' records reviewed, nursing staff did not implement facility's policy and procedure to ensure a patient care needs was met (Patient #1)

Specifically, nursing staff did not ensure that a patient identified as a risk for developing pressure ulcer was turned and repositioned as required.

Findings include:

Patient #1 is a 69- year- old female who was evaluated at the Emergency Department on 5/2/15 at 3:33 PM to rule out sepsis. The patient's medical condition included [DIAGNOSES REDACTED] (a progressive degeneration of the motor neurons of the central nervous system, leading to wasting of the muscles and paralysis), left scapular pressure ulcer, quadriplegia, and ventilator-dependent.

The initial nursing assessment of the patient in the Emergency Department on 5/2/16 at 3:33 PM noted an intact skin and no identified risk for developing pressure ulcer. This assessment was inconsistent with a second evaluation by another nurse on 5/2/16 at 5:22 PM that indicated the patient was quadriplegic, and not mobile in any extremities. The nurse noted the presence of left scapular ulcer.

Nursing notes on 5/2/16 and 5/3/16 did not reveal any documentation of turning, and repositioning of the patient during the thirteen hours she spent in the Emergency Department before she was admitted to the Intensive Care Unit.

Review of the facility's policy and procedure titled "Pressure Ulcer Prevention and Treatment," revised 02/08/16, noted that for patient at risk for developing pressure ulcers would be "Turn/reposition as determined by individual patient tissue tolerance or at a minimum every two hours".

On 5/6/16, a nurse identified a deep tissue injury measuring 5.1 centimeters (cm) x 3.0 cm .x 0.1 cm on the patient's sacrum.

During interview with Staff G, Emergency Department Manager on 9/29/16 at approximately 2:00 PM, she stated that general skin assessment is conducted on all patients seen in the Emergency Department, and those identified at risk for developing pressure ulcers should be repositioned every two (2) hours as per facility's policy.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation and interview, the facility failed to identify infection control hazards, to reduce the potential for transmission of infection.


Findings include:

During tours of the hospital on [DATE] and 9/30/2016, the following were identified:

Operating Rooms (OR):

1. The ceiling tiles of the old operating rooms (8 ORs- Examples included but were not limited to OR#14, #12, #11and # 8) were not monolithic ceiling type, which is required for OR rooms. There were gaps between most of the ceiling tiles in the ORs, and therefore it is not easy to clean and or wash these tiles for proper disinfection.

Medical Surgical Unit- Wallace Building- 7th floor:

The soiled utility room # 83 was found to have a positive airflow instead of the required negative airflow for this type of room.


Wallace Building- 2nd Floor Intensive Care Unit (ICU):

1. The ceiling tiles of the ICU rooms had Perforations (openings) for heating and cooling purposes, and were not the washable type that is required for the ICU. Examples of those rooms included, room 2001, 2002, 2003, 2004, 2005, 2006, 2007, and 2015.

2. The soiled utility room W28 was found to have a positive air pressure, instead of the required negative air pressure for this type of room.

3. The clean utility room of the ICU was found to have a neutral air pressure instead of the required positive air pressure for this type of room.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation, document review and staff interview, the hospital did not ensure that the condition of the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

During a tour of the facility on 9/26/2016 between 10:00 AM and 12:00 PM, the following were identified:

Emergency Department (ED):

1. The ceiling tiles of room 1041-ED in the Emergency Department was stained by water leak.

2. The exhaust grid above the restroom stall and the patient bed in Room 1165 (Behavioral health area) were big enough to permit looping and represent a potential for looping hazard.

3. The psychiatric patient rooms of the behavioral area of the ED had regular medical stretchers, which represent the potential for looping.


Medical Surgical Unit- Wallace Building- 7th floor:

During tour of the facility on 9/26/16 between 1:00 PM and 4:00 PM, the following were identified:

1. There was a gap in the levels of the floors of the patient room and the bathroom and there was no floor transition, which post a tripping hazard for patients and staff.

2. The soiled utility room #83 was found to have a positive airflow instead of the required negative airflow for this type of room.


Operating Rooms (OR):

1. The ceiling tiles of the old operating rooms (8 ORs- Examples included but were not limited to OR#s 14, #12, #11, and # 8) were not monolithic ceiling type, which is required for ORs. There were gaps between most of the ceiling tiles in the ORs, and therefore it is not easy to clean and or wash these tiles to ensure proper disinfection.


Wallace Building- 2nd Floor Intensive Care Unit (ICU):

1. The ceiling tiles of the ICU rooms had Perforations (openings) for heating and cooling purposes, and were not the washable type that is required for the ICU. Examples of those rooms included, room 2001, 2002, 2003, 2004, 2005, 2006, 2007, and 2015.

2. The soiled utility room W28 was found to have a positive air pressure, instead of the required negative air pressure for this type of room.

3. The clean utility room of the ICU was found to have a neutral air pressure instead of the required positive air pressure for this type of room.


North Building- 3rd floor (Psychiatric Unit):

During a tour of the Psychiatric Unit at approximately 10:55 AM in the presence of Staff L, Vice President of Facilities, and Staff K, Director of Engineering, the following were identified:

1. There was no mechanism in place at the unit entrance door to prevent elopement of patients once the door is opened for any reason.

2. There was a metal food cart on wheels about 4 feet high x 2 feet wide x 4 feet deep that was stored unattended on the psychiatric unit. This food cart can be used as a weapon by patients against staff or other patients.

3. All the doors of patients' rooms and their bathrooms were found to have protruded strike plates that can be used by a psychiatric patient to harm self or others.

4. The faucets of the hand wash sinks in patients' rooms and bathrooms were not the safety type, and they represent a potential for looping risk.

5. The water supply pipe to the toilets of all patients' bathrooms had gaps between them and the walls, and they represent a potential for looping risk.

6. In room 309, the cabinet that is mounted above the hand wash sink had regular handle that presents a potential for looping risk.

7. The louvers of the fan call units in some patient rooms (examples included but were not limited to rooms 303, 306) have gaps on the surfaces of the units and pose a potential for looping risk.

8. The cabinet of the above hand wash sink in room 309 had regular handles with gaps between the handles and the cabinets, which represent the potential for looping risk.

9. The fire hose cabinet at the end of the corridor next to stair 7 (Seven) was found to have 3 (Three) padlocks and door handles which represent looping risk.

10. The cover of a thermostat that was mounted on the wall of the corridor is square shaped with elevated lip on its surface, which represents a looping risk.

11. The Television screen mounted to the wall leaves a space between the wall and the screen, and there were also wirings and cables exposed, which represent a looping hazard.

12. The interview room for psychiatric patients was used for storage of items including two stretchers, a mattress, platform, etc. The storage of these items in the interview room poses a safety concern, e.g., may be utilized as a weapon for self harm or harm towards others.

13. The three fire extinguishers cabinet in the psychiatric unit was found to have handles and padlocks, which represent a looping hazard.


Cancer Center Building:

During a tour of the cancer Center Building in the afternoon of 9/29/2016, the following were identified:

1. Exam rooms #018 and #019 were found to have broken and missing cabinet doors handles. The handles of the cabinet in room #019 was attached to the cabinet by an adhesive duct tape.

2. The soiled utility room #038 was found to have positive air pressure instead of the required negative air pressure for this type of room.

3. The chemotherapy hoods in the infusion center's pharmacy were observed to have rusted surfaces and parts of their surfaces had peeled paints, which present an infection control concern.

4. The infusion center was observed to have only two hand wash sinks for 12 infusion bays instead of three (3); one hand wash sink per four bays is required.

5. The hospital has leased 10 bays out of the 15 bays to two different private practices. The two private practices were not separate and distinct from the Article 28 space as per the requirement of the New York State Department of Health for outpatient clinic.


Endoscopy Suite:

During a tour of the endoscopy suite on the afternoon of 9/30/2016, the following were identified in the presence of Staff L and K who acknowledged the following findings:

1. The bronchoscopy room was found to have a positive air pressure contrary to the negative air pressure that is required for this type of room.

2. The ceiling tiles of the minor surgery procedure rooms were loose metal ceiling tiles and had gaps in between the tiles which represents a potential for transmission of infections.

3. Two of three procedure rooms were cluttered and had more than one stretcher in the rooms.

All of the above findings were identified in the presence of the Vice President (VP) and the Director of Facilities, who acknowledged the findings.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on document review and interview, the facility's Performance Improvement program did not analyze data collected related to its discharge planning process and develop actions for on-going improvement to ensure an effective discharge planning process.

Findings include:

Review of the facility's 2016 " Performance Improvement Coordinating Group" (PICG) Annual Reporting Schedule showed no documentation that " 30 days re-admissions " were listed for review. The facility recorded the 30 days re-admissions rate, but did not present documented evidence that this information was reviewed, analyzed, or discussed by the QAPI team on a regular basis as deemed necessary. There was no evidence that they used this information to measure the effectiveness of the hospital discharge process and made changes if indicated.

During interview on 9/28/16 at 11:55 AM, Staff D, Director of Patient Services, and Case Management stated the number of patients readmitted to the hospital are reviewed and tracked.

Staff D did not provide any document for review during the interview and did not described how the tracked information was used to evaluate the effectiveness of the discharge planning process.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on document review and interview, the hospital's Governing Body did not ensure; 1) that the responsibility for grievance resolution was formally delegated to a grievance committee in writing; 2) prompt resolution of all grievances received by the facility.

Findings include:

1. Review of the document titled "Annual Meeting of Board of Trustees" held in December 17, 2015 noted that Staff A, Vice President, Patient Advocacy and Patient-Centered Support Services, was appointed for the operation of the facility's grievance process. The Board of Trustees appointed an individual instead of a committee of two or more people as prescribed by this regulation.

During interview with Staff A on 9/29/16 at approximately 3:30 PM, she confirmed that the Board of Trustees did not appoint a grievance committee but had appointed her to provide leadership of the facility's grievance process.

2. Review of the grievance data submitted monthly to the Performance Improvement Coordinating Group (PICG) from January 2016 to August 2016 revealed that seventy five percent of the grievances received during this period were not promptly resolved.

Review of the grievance data for 2013 and 2014 that were reported to the Board of Trustees in January 2014 and January 2015 respectively revealed there was no analysis of the timeliness of resolution of the grievances. There was no indication from the minutes that the Board of Trustees was reviewing and monitoring complaints and grievances for prompt resolution.

During interview with Staff B, Chief Medical Officer on 9/29/16 at approximately 3:25 PM, she stated the following: grievance data is reported to the PICG monthly and a yearly report is submitted to the Board of Trustees. However, since January 2015, the PICG will now report grievances to Board of Trustees once every two years. The Board of Trustees would receive the next grievance data by January 2017.

It was noted from the Board of Trustee meeting minutes that complaints/grievances received in 2015 and 2016 had not been reviewed by the facility's Board of Trustees.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on document review and staff interview, the facility did not have an effective grievance process to ensure the prompt resolution of all grievances.
This finding was evident in 15 of 15 grievance files reviewed (Files #s 1 through 15).

Failure to ensure prompt resolution of grievances denies patients the right to prompt resolution of their grievances.

Findings include:

Review of grievance File # 1 noted the following: the facility received a grievance from a complainant on 6/28/16, alleging inappropriate management of post-tonsillectomy symptoms during Emergency Department visit on 6/23/16.

The written response to the complainant was dated 8/12/2016, 44 days after the complaint was submitted.

Review of grievance File #2 noted that the facility received a grievance from the patient on 9/29/2015 who reported that she dislodged a bloody rubber glove and gauze from her vagina post discharge after an ambulatory surgery at the facility.

Review of the "Encounter Data" noted that the grievance was resolved on 2/1/2016, five (5) months after the complaint was received.

Similar findings regarding delay in the resolution of grievances were noted in grievance file #s three (3) through (15) where it took the facility between 12 days to six (6) months to resolve.

Review of the facility's policy and procedure titled, "Handling of Patient Complaints", last reviewed on 3/04/2015 noted the following: "A 30 day goal for resolution and response is communicated to the patient/patient representative. If this is not accomplished, the Patient Advocate will contact the patient by phone and inform them of the expected resolution date".

During interview with Staff A, Vice President, Patient Advocacy and Patient-Centered Support Services on 9/28/16 at approximately 11:45 AM, she acknowledged that most of grievances are resolved in 30 days and not in seven (7) days as required by regulation.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review and interview, the facility did not ensure that the Performance Improvement Program developed corrective action plan that addressed identified issues related to patient care.

Specifically, there was no corrective action plan implemented for the failure of nursing staff to repeat Accu-Checks (Blood glucose check) for patients with critical values of blood glucose.

Findings include:

Review of the facility's "Risk Safety Event" for 3/2016-9/2016 revealed more than 50 reportable incidents of nursing staff failure to repeat Accu-Checks for patients with critical value of blood glucose.

On 4/5/16, a patient's blood sugar level had a reading of greater than 600 milligram per deciliter (mg/dL). The Accu-Checks was not repeated to verify the blood glucose result as per the facility ' s policy requiring repeat of blood glucose for levels equal or below 45 mg/d/L or levels equal or higher than 450 mg/dL.

On 8/27/16, the Accu-Check showed a patient's blood sugar level of 22 mg/d/L. The Accu-Checks was not repeated to verify the blood glucose result.

On 8/28/16, Accu-Checks reading showed a patient's blood sugar of 37 mg/d/L. The Accu-Checks was not repeated to verify the blood glucose result.

Review of the Performance Improvement Coordinating Groups (PICG) minutes for April 18, 2016, showed there were 39 Accu-check critical values that were not repeated for the first quarter of 2015. The PICG minutes did not document the analysis of the issues and propose a corrective action plan to correct the identified problem.

During interview on 9/28/16 at 2:30PM, the above data was brought to the attention of Staff B, Chief Medical Officer, who stated that the hospital is aware of this "problem" and that "nursing quality was tracking it " .

Review of facility QAPI reports for 8/2015-7/2016 showed no documented evidence that the Nursing Department had analyzed the data and implemented corrective action.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on document review and interview, the facility did not ensure that the Performance Improvement Program developed corrective action plan that addressed identified issues related to patient care.

Specifically, there was no corrective action plan implemented for the failure of nursing staff to repeat Accu-Checks (Blood glucose check) for patients with critical values of blood glucose.

Findings include:

Review of the facility's "Risk Safety Event" for 3/2016-9/2016 revealed more than 50 reportable incidents of nursing staff failure to repeat Accu-Checks for patients with critical value of blood glucose.

On 4/5/16, a patient's blood sugar level had a reading of greater than 600 milligram per deciliter (mg/dL). The Accu-Checks was not repeated to verify the blood glucose result as per the facility ' s policy requiring repeat of blood glucose for levels equal or below 45 mg/d/L or levels equal or higher than 450 mg/dL.

On 8/27/16, the Accu-Check showed a patient's blood sugar level of 22 mg/d/L. The Accu-Checks was not repeated to verify the blood glucose result.

On 8/28/16, Accu-Checks reading showed a patient's blood sugar of 37 mg/d/L. The Accu-Checks was not repeated to verify the blood glucose result.

Review of the Performance Improvement Coordinating Groups (PICG) minutes for April 18, 2016, showed there were 39 Accu-check critical values that were not repeated for the first quarter of 2015. The PICG minutes did not document the analysis of the issues and propose a corrective action plan to correct the identified problem.

During interview on 9/28/16 at 2:30PM, the above data was brought to the attention of Staff B, Chief Medical Officer, who stated that the hospital is aware of this "problem" and that "nursing quality was tracking it " .

Review of facility QAPI reports for 8/2015-7/2016 showed no documented evidence that the Nursing Department had analyzed the data and implemented corrective action.