St. Francis Hospital
PFI # 0180
Revised: March 2003
Complaints:
| Complaint Information: | 2002 |
| Complaint Investigations Completed: | 5 |
| Complaints with Statements of Deficiencies (SOD) issued: | 5 |
| % of Complaints with SODs Issued | 100% |
| Regional % of Complaints with SODs issued: | 23.3% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
| 1/22/02 | 405.2(b)(2) | Governing Body | 2/25/03 |
| 405.4(a)(1)(i)(2) | Medical Staff | ||
| 405.5(b)(1)(i)(ii)(2)(ii)(3)(4)(c)(e) | Nursing Services | ||
| 405.6(b)(5) | Quality Assurance Program | ||
| 405.7(b)(3)(5)(9) | Patients' Rights | ||
| 405.10(c)(1)(8) | Medical Records | ||
| 405.9(b)(12)(f)(1) | Admission/Discharge | ||
| 405.18(c) | Rehabilitation Services | ||
| 3/1/02 | 405.2(b)(2) | Governing Body | 12/23/02 |
| 405.4(a)(1)(i)(2) | Medical Staff | ||
| 405.5(b)(3)(4)(c) | Nursing Services | ||
| 405.7(b)(9)(13)(16) | Patients' Rights | ||
| 405.9(f)(1) | Admission/Discharge | ||
| 405.19(e)(1)(5) | Emergency Services | ||
| 10/17/02 | 405.2(b)(2) | Governing Body: Organization and Operation | 2/3/03 |
| 405.19(e)(1) | Emergency Services: Patient Care | ||
| 10/17/02 | 405.5(b)(2) | Nursing Services: Delivery of Services | 2/3/03 |
| 405.5(b)(4) | Nursing Services: Delivery of Services | ||
| 405.19(e)(1) | Emergency Services: Patient Care | ||
| 10/17/02 | 405.5(b)(2)(b)(3)(b)(4) | Nursing Services: Delivery of Services | PoC not finalized |
| 405.25(b)(3) | Organ and Tissue Donation-Anatomical Gifts |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
| 6/11/02 | Article 28 Focused Survey | 405.2(a) (b)(2) | Governing Body | 1/28/03 |
| 405.2(b)(2) | Governing Body: Organization and Operation | |||
| 405.2(f)(1) | Governing Body: Care of Patients | |||
| 405.5 | Nursing Services | |||
| 405.5(b)(4) | Nursing Services: Delivery of Services | |||
| 405.6 | Quality Assurance Program | |||
| 405.7(a)(2) | Patients' Rights: Procedural Requirements | |||
| 405.7(b)(3)(9)(13) | Patients' Rights: Hospital Responsibilities | |||
| 405.11(b) | Infection Control | |||
| 405.19(c)(6) | Emergency Services | |||
| 405.19(d)(1)(i)(a)(iv) | Emergency Services: Staffing | |||
| 405.19(e)(1)(e)(2)(e)(5) | Emergency Services: Patient Care | |||
| 10/17/02 | Article 28 Focused Survey | 405.2(b)(2) | Governing Body: Organization and Operation | |
| 405.4(a)(1)(i) | Medical Staff: Medical Staff Accountability | |||
| 405.5(b)(1)(i) | Nursing Services: Delivery of Services | |||
| 405.7(b)(5) | Patients' Rights: Hospital Responsibilities | |||
| 405.19(e)(1)(e)(2) | Emergency Services: Patient Care | Due 3/11/03 | ||
Most Recent Survey Date: 10/17/02
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |