North Shore University Hospital - Manhasset

PFI # 0541

Revised: 3/21/03

Complaints:

Complaint Information: 2002
Complaint Investigations Completed: 25
Complaints with Statements of Deficiencies (SOD) issued: 16
% of Complaints with SODs Issued 64%
Regional % of Complaints with SODs issued: 53.9%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
8/02/02 405.5 Nursing services
(b) Delivery of services
(e) Quality assurance
12/10/02
  405.7 Patients’ rights
(b) Hospital responsibilities
 
12/12/02 405.7 Patients’ rights
(b) Hospital responsibilities
1/31/03
7/22/02 405.4 Medical staff
(a) Medical staff accountability
(f) Post graduate trainees
1/07/03
7/30/02 405.5 Nursing services
(b) Delivery of services
(e) Quality assurance
12/10/02
  405.6 Quality assurance program
(a) Quality assurance committee
 
  405.7 Patients’ rights
(b) Hospital responsibilities
 
4/04/02 405.7 Patients’ rights
(b) Hospital responsibilities
NO POC REQUIRED
9/18/02 405.5 Nursing services
(b) Delivery of services
11/27/02
  405.7 Patients’ rights
(b) Hospital responsibilities
 
6/26/02 405.5 Nursing services
(b) Delivery of services
9/26/02
  405.6 Quality assurance program
(b) Activities of the quality assurance committee
 
  405.7 Patients’ rights
(b) Hospital responsibilities
 
  405.8 Incident reporting
(a) Delay in reporting incident
 
2/25/02 405.4 Medical staff
(c) Medical staff bylaws
NO POC REQUIRED
  405.7 Patients’ rights
(b) Hospital responsibilities
5/06/02
  405.19 Emergency services
(e) patient care
NO POC REQUIRED
3/15/02 405.12 Surgical services
(a) Organization and direction
5/16/02
10/23/02 405.19 Emergency services
(e) Patient care
12/10/02
2/27/02 405.19 Emergency services
(e) Patient care
5/06/02
10/10/02 405.4 Medical staff
(a) Medical staff accountability
3/18/03
  405.5 Nursing services
(b) Delivery of services
(e) Quality assurance
 
  405.9 Admission/Discharge  
  405.19 Emergency services
(e) Patient care
 
10/23/02 405.4 Medical staff
(c) Medical staff bylaws
1/07/03
  405.7 Patients’ rights
(b) Hospital responsibilities
 
10/23/02 405.7 Patients’ rights
(b) Hospital responsibilities
3/19/03
7/26/02 405.7 Patients’ rights
(b) Hospital responsibilities
12/19/02
  405.12 Surgical services
(b) Operation and service delivery
 
  711.4 General structural, equipment and safety standards for existing hospital
Pertinent technical standards
Nursing units
 
12/06/02 405.5 Nursing services
(b) Delivery of services
3/20/03
  405.6 Quality assurance program
(b) Activities
 

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
1/28/02 Resident Work Hours
405.4
Medical staff
(b) Organization
5/19/02

Most Recent Survey Date:

Areas Cited as a Result of Incident Investigations:

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