OUR LADY OF MERCY MEDICAL CENTER
PFI # 1168
Revised: June 2001
Complaints:
| Complaint Information: | 2000 |
| Complaint Investigations Completed: | 11 |
| Complaints with Statements of Deficiencies (SOD) issued: | 3 |
| % of Complaints with SODs Issued | 27% |
| Regional % of Complaints with SODs issued: | 21.5% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
| 11/24/00 | 405.05 | Nursing Services | 02/02/01 |
| 11/24/00 | 405.23 | Food and Dietetic Services | 02/02/01 |
| 03/01/00 | 405.04 | Medical Staff - Medical Staff Bylaws | 05/09/00 |
| 03/01/00 | 405.07 | Patients' Rights - Hospital Responsibilitie | 05/09/00 |
| 03/01/00 | 405.09 | Admission/Discharge - Domestic Violence | 05/09/00 |
| 03/01/00 | 405.10 | Medical Records - General Requirement | 05/09/00 |
| 03/01/00 | 405.19 | Emergency Services - Patient Care | 05/09/00 |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
Most Recent Survey Date:
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
| 01/13/00 | 405.05 | Nursing Services - Delivery Of Services | 05/05/00 |
| 01/13/00 | 405.06 | Quality Assurance Program | 05/05/00 |
| 01/13/00 | 405.07 | Patients' Rights - Hospital Responsibilities | 05/05/00 |
| 01/13/00 | 405.08 | Incident Reporting - Investigative Report | 05/05/00 |
| 02/24/00 | 400.03 | Inspection, Reproduction, and Reports | |
| 02/24/00 | 405.06 | Quality Assurance Program | |
| 02/24/00 | 405.08 | Incident Reporting - Definitions | |
| 09/25/00 | 405.04 | Medical Staff - Postgraduate | 12/14/00 |
| 09/25/00 | 405.06 | Quality Assurance Program - QA Committee | 12/14/00 |