Brookhaven Memorial
PFI # 0885
Revised: 4/20/01
Complaints:
| Complaint Information: | 2000 |
| Complaint Investigations Completed: | 20 |
| Complaints with Statements of Deficiencies (SOD) issued: | 17 |
| % of Complaints with SODs Issued | 85% |
| Regional % of Complaints with SODs issued: | 55.6% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
| 7/14/00 | 405.7 | Patients’ rights (b) Hospital responsibilities | 9/26/00 |
| 405.10 | Medical records (a) General requirements | ||
| 9/27/00 | 405.5 | Nursing services (b) Delivery of services (e) Quality assurance | 12/18/00 |
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 9/27/00 | 405.5 | Nursing services (b) Delivery of services (e) Quality assurance | 12/18/00 |
| 405.9 | Admission/discharge (f) Discharge | ||
| 7/27/00 | 405.5 | Nursing (a) Organization and staffing (b) Delivery of services | 11/16/00 |
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.10 | Medical records (a) General requirements | ||
| 405.19 | Emergency services (c) General policies and procedures (e) Patient care | ||
| 9/27/00 | 405.12 | Surgical services (a) Organization and direction | 12/18/00 |
| 9/28/00 | 405.7 | Patients’ rights (b) Hospital responsibilities | No POC Required |
| 405.15 | Radiological and nuclear medicine services (a)General provisions for diagnostic and therapeutic radiological services (4)Personnel | ||
| 405.19 | Emergency services (e) Patient care | ||
| 9/27/00 | 405.19 | Emergency services (e) Patient care | No POC Required |
| 5/1/99 | 405.7 | Patients’ rights (b) Hospital responsibilities | 1/25/01 |
| 405.19 | Emergency Services (e) Patient care (f) Quality assurance | ||
| 1/7/00 | 405.2 | Governing Body (c) Compliance with federal, state, and local laws | 8/4/00 |
| 405.3 | Administration (a) The Chief Executive Officer | ||
| 405.4 | Medical staff (a) Medical staff accountability | ||
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.19 | Emergency Services (e) Patient care (f) Quality assurance | ||
| 11/1/99 | 405.5 | Nursing services (b) Delivery of services (e) Quality assurance | 11/8/00 |
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.19 | Emergency services (e) Patient care | ||
| 1/7/00 | 405.2 | Governing Body (c) Compliance with federal, state, and local laws | 8/4/00 |
| 405.3 | Administration (a) The Chief Executive Officer | ||
| 405.4 | Medical staff (a) Medical staff accountability | ||
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.19 | Emergency Services (e) Patient care (f) Quality assurance | ||
| 9/27/00 | 405.5 | Nursing services (b) Delivery of services | 12/18/00 |
| 9/27/00 | 405.5 | Nursing services (b) Delivery of services (e) Quality assurance | 12/18/00 |
| 405.6 | Quality assurance program (a) Governing body shall establish a quality assurance committee | ||
| 3/10/00 | 405.7 | Patients’ rights (b) Hospital responsibilities | 5/3/00 |
| 405.20 | Outpatient services (d) Hospital – based ambulatory surgery service | ||
| 10/06/00 | 405.4 | Medical staff (a) Medical staff accountability (c) Medical staff bylaws | No POC required |
| 7/27/00 | 405.5 | Nursing (a) Organization and staffing (b) Delivery of services | 11/16/00 |
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.10 | Medical records (a) General requirements | ||
| 405.19 | Emergency services (c) General policies and procedures (e) Patient care | ||
| 9/27/00 | 405.9 | Admission/discharge (f) Discharge (g) Hospital inpatient discharge review program | 12/18/00 |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
| April 12-15 1999 | JCAHO | Full Survey | 5/11/1999 |
Most Recent Survey Date:
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |