Hospital Complaint and Survey Information - 2003

Hospital Name: MERCY HOSPITAL

PFI # 0213

Complaint Information:

Calendar Year: 2003
Complaint Investigations Completed 20
Complaints with Statements of Deficiencies (SOD) Issued 5
% of Complaints with SODs Issued 25 %
Regional % of Complaints with SODs Issued 36.4%

Areas Cited as a Result of Complaint Investigations:

SOD Date Regulatory Citation Areas Cited Date Plan of Correction Accepted
9/26/2003 405.5 Nursing Services Delivery of Services 10/23/03
6/6/2003 405.6 Quality Assurance Program

QA Committee

 7/9/03
6/6/2003 405.5 Medical Staff

Medical Staff Accountability

 7/9/03
6/6/2003 405.19 Emergency Services General 7/9/03
6/4/2003 405.7 Patients' Rights

Hospital Responsibilities

 7/22/03
6/4/2003 405.6 Quality Assurance Program

QA Committee

 7/22/03
6/4/2003 405.5 Nursing Services Delivery of Services 7/22/03
6/4/2003 405.4 Medical Staff

Medical Staff Accountability

 7/22/03
6/4/2003 405.10 Medical Records General Requirements 7/22/03
5/20/2003 405.5 Nursing Services Delivery of Services 7/22/03
5/20/2003 405.4 Medical Staff

Medical Staff Accountability

 7/22/03
5/20/2003 405.21 Maternity and Newborn Services

General Requirements

 7/22/03
5/20/2003 405.2 Governing Body

Care of Patients

 7/22/03
3/31/2003 405.5 (b) (2) Nursing Services Delivery of Services 4/02/03
3/31/2003 405.15 (a) (4) Services Gen. Prov. For Diag. And Ther. Rad. Svcs. 4/02/03

Areas Cited as a Result of Surveys: 0

Most Recent Survey Date: 9/10/03 (PPS)

Areas Cited as a Result of Incident Investigations:

SOD Date Regulatory Citation Areas Cited Date Plan of Correction Accepted
2/25/2003 405.8 Incident Reporting

Investigative Report

 3/31/03
2/25/2003 405.7 Patients' Rights Hospital Responsibilities 3/31/03
2/25/2003 405.5 Nursing Services Delivery of Services 3/31/03
2/25/2003 405.2 Governing Body Care of Patients 3/31/03
2/25/2003 405.13 Anesthesia Services Operation and Service Delivery 3/31/03
2/25/2003 405.12 Surgical Services Operation and Service Delivery 3/31/03
1/13/2003 405.6 Quality Assurance Program QA Committee 4/25/03
1/13/2003 405.5 Nursing Services Delivery of Services 4/25/03
1/13/2003 405.4 Medical Staff Medical Staff Accountability 4/25/03
1/13/2003 405.2 Governing Body Care of Patients 4/25/03
1/13/2003 405.19 Emergency Services Patient Care 4/25/03
1/13/2003 405.13 Anesthesia Services Operation and Service Delivery 4/25/03
1/13/2003 405.12 Surgical Services Organization and Direction 4/25/03