Good Samaritan Hospital

PFI # 0925

Revised: 04/01

Complaints:

Complaint Information: 2000
Complaint Investigations Completed: 29
Complaints with Statements of Deficiencies (SOD) issued: 16
% of Complaints with SODs Issued 55%
Regional % of Complaints with SODs issued: 55.6%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
5/31/00 405.4 Medial staff (i) Autopsies 11/13/00
  405.5 Nursing services (b) Delivery services  
8/10/00 405.4 Medial staff (i) Autopsies 12/18/00
  405.5 Nursing services (b) Delivery services  
  405.6 Quality assurance program (a) Governing body  
  405.11 Infection control  
  405.16 Laboratory services (b) Hospital maintain  
10/13/00 405.5 Nursing services (b) Delivery of services 12/14/00
  405.7 Patients’ rights (b) Hospital responsibilities  
  405.19 Emergency services (e) Patient care  
10/12/00 405.4 Medical staff (b) Organization 12/08/00
  405.6 Quality Assurance (a) Quality assurance program  
10/13/00 405.24 Environmental health (e) Housekeeping No POC Required
10/13/00 405.7 Patients’ rights (b) Hospital responsibilities 11/30/00
  405.10 Medical records (a) General requirements  
  405.15 Radiologic and nuclear medicine services    
11/05/99 405.5 Nursing services (b) Delivery of services No POC Required
  405.28 Social Services (a) Patient shall be screened prior to  
3/27/00 405.19 Emergency services (e) Patient care 4/18/00
10/01/99 405.4 Medical staff (a) Medical staff accountability 8/14/00
  405.7 Patients’ rights (b) Hospital responsibilities  
11/02/99 405.28 Social Services (a) Patient shall be screened prior to 6/22/00
11/19/99 405.5 Nursing services (b) Delivery of services (e) Quality assurance 8/14/00
  405.6 Quality assurance program (a) Governing body  
  405.7 Patient rights (b) Hospital responsibilities  
  405.13 Anesthesia services (b) Operation and service delivery  
  405.23 Dietary service  
  405.24 Environmental health (b) Life safety from fire  
10/13/00 405.5 Nursing services (b) Delivery of services 12/14/00
  405.7 Patients’ rights (b) Hospital responsibilities  
10/24/00 405.19 Emergency services 1/25/01
4/24/00 405.2 Governing Body (c) Compliance with Federal, State, and local laws 6/6/00
7/21/00 405.5 Nursing services (a) Organization and staffing NO POC Required
  405.7 Patient rights (b) Hospital responsibilities  
10/13/00 405.5 Nursing services (c) Administration of drugs NO POC Required
  405.7 Patient rights (b) Hospital responsibilities  

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
Article 28 10/13/00 405.3 Administration (b) Personnel 11/22/00
  405.4 Medical staff (a) Medical staff accountability  
  405.6 Quality assurance (a) Quality assurance committees  
  405.7 Patients’ rights (b) Hospital responsibilities  
  405.9 Admission/discharge (b) Admission  
  405.10 Medical records (a) General requirements  
  405.15 Radiological services (a) General provision  
  405.19 Emergency services (e) Patient care  

Most Recent Survey Date:

Areas Cited as a Result of Incident Investigations:

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