University Hospital
PFI # 0245
Revised: 3/21/03
Complaints:
| Complaint Information: | 2002 |
| Complaint Investigations Completed: | 21 |
| Complaints with Statements of Deficiencies (SOD) issued: | 10 |
| % of Complaints with SODs Issued | 48% |
| Regional % of Complaints with SODs issued: | 53.9% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
| 10/2001 | 405.4 | Medical staff (a) Medical staff accountability | 10/07/02 |
| 2/21/01 | 405.19 | Emergency services (e) Patient care | 2/14/03 |
| 4/19/02 | 405.5 | Nursing services (b) Delivery of services | NO POC REQUIRED |
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 2/11/02 | 405.2 | Governing body (b) Organization and operation (c) Compliance with federal, state and local laws (f) Care of patients | 7/09/02 |
| 405.3 | Administration (b) Personnel | ||
| 405.4 | Medical staff (a) Medical staff accountability | ||
| 405.5 | Nursing services (a) Organization and staffing (b) Delivery of services (e) Quality assurance | ||
| 405.6 | Quality assurance program (a) Governing body | ||
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.17 | Pharmaceutical services (a) Organization and direction (b) Operation and service delivery | ||
| 10/11/02 | 405.7 | Patients’ rights (b) Hospital responsibilities | NO POC REQUIRED |
| 1/30/02 | 405.3 | Administration (a) Chief executive officer | 8/07/02 |
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.9 | Admission/discharge (f) Discharge | ||
| 6/28/02 | 405.7 | Patients’ rights (b) Hospital responsibilities | 1/07/03 |
| 405.19 | Emergency services (e) Patient care | ||
| 8/05/02 | 405.4 | Medical staff (a) Medical staff accountability | 1/07/03 |
| 405.7 | Patients’ rights (b) Hospital responsibilities | ||
| 405.19 | Emergency services (c) General policies and procedures (e) Patient care | ||
| 6/11/02 | 405.7 | Patients’ rights (b) Hospital responsibilities | 1/07/03 |
| 405.19 | Emergency services (c) General policies and procedures (e) Patient care (f) Quality assurance | ||
| 11/22/02 | 405.7 | Patients’ rights (b) Hospital responsibilities | NO POC REQUIRED |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
| 6/28/02 | Article 28 405.5 | Nursing services (b) Delivery of services (c) Administration of drugs | 9/24/02 |
| 405.6 | Quality assurance program (a) Governing body | ||
| 405.17 | Pharmaceutical services (b) Operation and service delivery | ||
| 4/12/02 | Resident Work Hours 405.4 | Medical staff (b) Organization | 7/22/02 |
Most Recent Survey Date:
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |