Hospital Name: MONTEFIORE MEDICAL CENTER/MOSES HOSPITAL DIVISION

PFI # 1169

Revised: Month Year

Complaints:

Complaint Information: 2002
Complaint Investigations Completed: 11
Complaints with Statements of Deficiencies (SOD) issued: 8
% of Complaints with SODs Issued 73%
Regional % of Complaints with SODs issued: 44.9%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
03/14/02 405.04 Medical Staff - Medical Staff Accountability 10/04/02
03/14/02 405.20 Outpatient Services - General Requirements 04/26/02
04/04/02 405.07 Patients' Rights - hospital Responsibilities 04/04/02
07/03/02 405.05 Nursing Services 07/03/02
07/03/02 405.06 Quality Assurance 10/21/02
08/08/02 405.05 Nursing Services - Delivery of Services 10/18/02
08/08/02 405.07 Patients' Rights - Hospital Responsibilities 10/18/02
08/08/02 405.19 Emergency Services - Patient Care 10/18/02
11/12/02 405.05 Nursing Services - Delivery of Services 01/07/03
11/12/02 405.10 Medical Records - General Requirements 01/07/03
11/12/02 405.04 Medical Staff - Medical Staff Accountability 02/06/03
11/12/02 405.05 Nursing Services - Delivery of Services 02/06/03

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
07/25/02 A28 405.04 Medical Staff - Organization 10/09/02
07/25/02 A28 405.04 Medical Staff - Organization 10/09/02
07/25/02 A28 405.04 Medical Staff - Organization 10/09/02
07/25/02 A28 405.04 Medical Staff - Organization 10/09/02

Most Recent Survey Date:

Areas Cited as a Result of Incident Investigations:

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