St. Luke's Memorial Hospital Center

PFI # 0599

Complaints:

Complaint Information: 1998
   
Complaint Investigations Completed 6
Complaints with Statements of Deficiencies (SOD) Issued 3
% of Complaints with SODs Issued 50%
Regional % of Complaints with SODs Issued: 36.7%

Areas Cited as a Result of Complaints:

SOD Date Regulatory Citation Areas Cited as a Result of Complaints: Date Plan of Correction Accepted
4/17/98 405.2(a) Governing Body – Legally Responsible 6/5/98
  405.5(b) Nursing Services – Delivery of Services  
  405.7(b) Patients’ Rights – Hospital Responsibilities  
  405.10 Medical Records  
4/23/98 405.6(a) Quality Assurance – QA Committee 5/29/98
  405.25(a) Request for Consent to an Anatomical Gift – Definitions  
  405.28(a) Social Services – Screening  
8/19/98 405.5(b) Nursing Services – Delivery of Services 8/19/98

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited as a Result of Complaints: Date Plan of Correction Accepted
3/11/98 Initial ESRD Cert 405.2136(d) - Governing Body & Management – Safe Sanitary Environment 3/23/98
    405.2136(f) - Governing Body & Management – Patient Care Policies  
    405.2140(b) - Physical Environment – Functional & Sanitary Environment  
    405.2140(d) - Physical Environment – Emergency Preparedness  
6/9-10/98 Medicare ESRD Recert & Article 28 400.21(d) - All Facilities - Advance Directives – Policies & Procedures 8/18/98
    405.10(b) - Medical Records – Content    
    405.2137(a) - Patient Long Term Program & Patient Care Plan - Written – Long-Term Plan  
    405.2138(e) - Patients’ Rights & Responsibilities – Grievance Mechanism  
    405.2139(a) - Medical Records – Care Plans  
    405.2140(b) - Physical Environment – Functional & Sanitary  

Areas Cited as a Result of Incident Investigations:

SOD Date Regulatory Citation Areas Cited as a Result of Complaints: Date Plan of Correction Accepted