Nassau University Medical Center
PFI # 0528
Revised: 3/02
Complaints:
| Complaint Information: | 2001 |
| Complaint Investigations Completed: | 22 |
| Complaints with Statements of Deficiencies (SOD) issued: | 13 |
| % of Complaints with SODs Issued | 59% |
| Regional % of Complaints with SODs issued: | 54.3% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
| 1/03/01 | 405.4 | Medical staff (a) Medical staff accountability (c) Medical staff bylaws (i) Autopsies | 3/23/01 |
| 405.5 | Nursing services (b) Delivery of services | ||
| 405.6 | Quality assurance program (a) Governing body | ||
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.19 | Emergency services (e) Patient care | ||
| 11/07/01 | 405.2 | Governing body (c) Compliance with Federal, State and local laws (d) Chief executive officer (e) Medical staff | 12/26/01 |
| 405.3 | Administration (a) Chief executive officer (b) Personnel | ||
| 405.4 | Medical staff (b) Organization | ||
| 405.6 | Quality assurance program (b) Activities of the quality assurance program | ||
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.10 | Medical records (a) General requirements | ||
| 405.19 | Emergency services (e) Patient care (f) Quality assurance | ||
| 5/11/01 | 405.17 | Pharmaceutical services (a) Organization and direction (c) Physical facilities | 6/8/01 |
| 5/11/01 | 405.2 | Governing body (c) Compliance with Federal, State and local laws (d) Chief executive officer | 6/27/01 |
| 405.3 | Administration (a) Chief executive officer | ||
| 405.7 | Patients’ rights (a) Procedural requirements (b) Hospital responsibilities | ||
| 405.19 | Emergency services (b) Organization (f) Quality assurance | ||
| 4/01/01 | 405.5 | Nursing services (b) Delivery of services | 7/10/01 |
| 4/12/01 | 405.2 | Governing body (c) Compliance with Federal, State and local laws (d) Chief executive officer | 5/21/01 |
| 405.3 | Administration (a) Chief executive officer | ||
| 405.4 | Medical staff (a) Medical staff accountability | ||
| 405.6 | Quality assurance program (b) Activities of the quality assurance program | ||
| 405.7 | Patients’ rights (a) Procedural requirements (b) Hospital responsibilities | ||
| 405.9 | Admission/discharge (f) Discharge | ||
| 405.10 | Medical records (a) General requirements | ||
| 405.19 | Emergency services (e) Patient care | ||
| 6/25/01 | 405.10 | Medical records (a) General requirements | 9/10/01 |
| 5/7/01 | 405.4 | Medical staff (f) Postgraduate trainees | 7/16/01 |
| 405.5 | Nursing services (b) Delivery of services | ||
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 3/16/01 | 405.7 | Patients’ rights (b) Hospital responsibilities | 6/14/01 |
| 405.19 | Emergency services (e) Patient care (f) Quality assurance | ||
| 7/02/01 | 405.5 | Nursing services (b) Delivery of services | 8/10/01 |
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.10 | Medical records (a) General requirements (b) Content | ||
| 7/02/01 | 405.19 | Emergency services (e) Patient care | NO POC NEEDED |
| 6/01/01 | 405.4 | Medical staff (a) Medical staff accountability (b) Medical staff bylaws | 3/18/02 |
| 405.5 | Nursing services (c) Administration of drugs (e) Quality assurance | ||
| 405.6 | Quality assurance program (a) Quality assurance committee | ||
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.9 | Admission/Discharge (f) Discharge | ||
| 405.28 | Social Services (a) Patient shall be screened prior to or upon admission to determine the need for social services | ||
| 7/24/01 | 405.5 | Nursing services (b) Delivery of services | 10/10/01 |
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.19 | Emergency services (e) Patient care |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
| 7/25/01 | Article 28 405.5 | Nursing services (b) Delivery of services (e) Quality assurance | 9/13/01 |
| 405.6 | Quality assurance program (b) Activities of the quality assurance program | ||
| 405.7 | Patients’ rights (b) Hospital responsibilities |
Most Recent Survey Date:
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |