Southside Hospital

PFI # 0924

Revised: 3/21/03

Complaints:

Complaint Information: 2002
Complaint Investigations Completed: 7
Complaints with Statements of Deficiencies (SOD) issued: 4
% of Complaints with SODs Issued 57%
Regional % of Complaints with SODs issued: 53.9%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
8/27/02 405.4 Medical staff (b) Organization 11/06/02
12/12/01 405.2 Governing body (b) Organization and operation (f) Care of patients 9/23/02
  405.4 Medical staff (a) Medical staff accountability  
  405.5 Nursing service (b) Delivery of services  
  405.6 Quality assurance program (a) Governing body (b) Activities of the quality assurance committee  
  405.7 Patients’ rights (b) Hospital responsibilities  
  405.8 Incident reporting (b) Incidents required to be reported  
3/05/02 405.19 Emergency services (e) Patient care (f) Quality assurance 7/09/02
9/30/02 405.5 Nursing services (b) Delivery of services 11/27/02
  405.7 Patients’ rights (b) Hospital responsibilities  

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
1/31/02 Resident Work Hours 405.4 Medical staff (b) Organization 4/18/02
3/27/02 Article 28 405.2 Governing body (c) Compliance with federal, state and local laws 5/01/02
  405.3 Administration (b) Personnel  
  405.5 Nursing services (b) Delivery of services  
  405.10 Medical records (a) General requirements  
  405.11 Infection control  
  405.19 Emergency services (e) Patient care  
  405.23 Food and dietetic services (a) General  
  405.24 Environmental health (a) Building and grounds (b) Life safety form fire (e) Housekeeping (f) Linen and laundry  
  Part 711 – General standards of construction    
  711.2 Pertinent technical standards (a) (1) NFPA 101-1997 Life safety code (a) (26) NFPA 99-1996 Standards for health care facilities (c) Design standards for the disabled  
  711.4 General structural, equipment and safety standards for existing hospitals (a) Pertinent technical standards (aa) Mechanical requirements  

Most Recent Survey Date:

Areas Cited as a Result of Incident Investigations:

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