Albert Lindley Lee Memorial Hospital

PFI # 0724

Complaints:

Complaint Information: 2000
   
Complaint Investigations Completed 4
Complaints with Statements of Deficiencies (SOD) Issued 2
% of Complaints with SODs Issued 50%
Regional % of Complaints with SODs issued: 30.6%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
4/7/00 405.2(f) Governing Body – Care of Patients 8/30/00
  405.5 Nursing Services  
  405.6 Quality Assurance  
  405.7(b) Patients’ Rights – Hospital Responsibilities  
  405.9(f) Admission/Discharge – Discharge  
  405.10(b) Medical Records – Content  
  405.12(b) Surgical Services – Operation/Service Delivery  
5/3/00 400.21(c) Advance Directives – Facility Compliance 8/17/00
  405.2(b) Governing Body – Organization & Operation  
  405.2(f) Governing Body – Care of Patients  
  405.5(b) Nursing Services – Delivery of Services  
  405.6 Quality Assurance  
  405.13(b) Anesthesia Services – Operation/Service Delivery  
  405.19(e) Emergency Services – Patient Care  
  405.43(a) Orders Not to Resuscitate - Policies & Procedures  
       

Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
2/23/00 Article 28 Focus None  
6/14/2000 COBRA Survey HCFA issued statement of deficiencies 12/1/00  

Incident Investigations:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted