Good Samaritan Hospital

PFI # 0779

Revised: March 2003

Complaints:

Complaint Information: 2002
Complaint Investigations Completed: 8
Complaints with Statements of Deficiencies (SOD) issued: 4
% of Complaints with SODs Issued 50%
Regional % of Complaints with SODs issued: 23.3%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
2/11/02 405.19(e)(1) Emergency Services 6/6/02
       
2/11/02 405.3(a) Administration 9/24/02
  405.6(a)(2)(ii)(iii)(iv)(v)(vi)vii) Quality Assurance Program  
  405.19(e)(5) Emergency Services  
       
5/16/02 405.5 Nursing Services 9/24/02
  405.5(b)(1)(ii) Nursing Services - Delivery of Services  
  405.5(b)(4) Nursing Services - Delivery of Services  
       
9/12/02 405.5(b)(3) Nursing Services - Delivery of Services 11/12/02
  405.5(b)(4) Nursing Services - Delivery of Services  

Areas Cited as a Result of Surveys:

Date of Survey Type Regulatory Citation Areas Cited: Date Plan of Correction Accepted
2/8/02 Title 18 Dialysis Re-certification Survey 405.2136 COP Governing Body and Management 4/1/02
    405.2136 GB Health and Safety  
    405.2136(d)(2) Personnel P/P: Safe and Sanitary Environment  
    405.2136(d)(6) Personnel P/P: Staff Education  
    405.2136(g)(1) Medical Supervision: Orders  
    405.2136(g)(1) Medical Supervision: Plans of Care  
    405.2137 COP Long Term Program & Care Plan  
    405.2137(a) Written Long-Term Plan  
    405.2137(b) PCP: Written Assessment Based  
    405.2139 COP Medical Records  
    405.2139(a) Med Records: Identify, Justify, Document  
    405.2139(a) Med Records: Pt Assessments  
    405.2139(a) Med Records: ID & Social Data  
    405.2139(a) Med Records: Med & Nursing History  
    405.2139(a) Med Records: Physician Exams  
    405.2139(a) Med Records: Orders  
    405.2139(a) Med Records: Progress Notes  
    405.2139(a) Med Records: Treatments and Findings  
    405.2139(d) Med Records: Self-care Home Patients  
    410.2140(a) PE: Construction & Maintain for Safety  
    405.2140(a)(3) PE: Free of Hazards  
    405.2140(b) PE: Functional, Sanitary and Comfortable  
    405.2140(d)(1) ER: Written Plan  
    405.2161 COP Director of a Renal Dialysis FAC  

Most Recent Survey Date: 2/8/02

Areas Cited as a Result of Incident Investigations:

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