Hospital Complaint and Survey Information - 2003

Winthrop University Hospital

PFI # 0511

Revised: 4/04

Complaint Information:

Calendar Year: 2003
Complaint Investigations Completed: 20
Complaints with Statements of Deficiencies (SOD) issued: 11
% of Complaints with SODs Issued 55%
Regional % of Complaints with SODs issued: 49.2%

Areas Cited

SOD Date Regulatory Citation Areas Cited Date Plan of Correction Accepted
9/29/03 405.7 Patients’ rights
(b)(3) Hospital responsibilities
(b)(23) Hospital responsibilities		 2/12/04
  405.19 Emergency services
(d)(1)(iv) Staffing		  
7/24/03 405.5 Nursing services
(b) (1)(ii) Delivery of services
(b)(4) Delivery of services		 9/25/03
1/13/03 405.7 Patients’ rights
(b)(19) Hospital responsibilities		 5/02/03
7/07/03 405.7 Patients’ rights
(b)(3) Hospital responsibilities		 12/19/03
10/08/03 405.4 Medical staff
(a) (1)(i ) Medical staff accountability		 12/19/03
  405.6 Quality assurance
(a) (2)(v) Program		  
  405.7 Patients’ rights
(b)(3) Hospital responsibilities		  
  405.8 Incident reporting
(b) (1) Incidents to be reported		  
  405.10 Medical records
(b)(2)(i) Content		  
1/30/03 405.7 Patients’ rights
(b)(3) Hospital responsibilities		 NO POC REQUIRED
1/30/03 405.5 Nursing services
(c)(2) Administration of drugs
(e) Quality assurance		 7/18/03
  405.7 Patients’ rights
(b) (8) Hospital responsibilities		  
10/08/03 405.6 Quality assurance program
(b) (1) Activities		 12/19/03
  405.7 Patients’ rights
(b) (23) Hospital responsibilities;		  
1/30/03 405.5 Nursing services
(b)(1)(i) Delivery of services
(c)(2) Administration of drugs		 NO POC REQUIRED
  405.7 Patients’ rights
(b) (3) Hospital responsibilities		  
  405.17 Pharmaceutical services
(b) Operation and service delivery		  
10/08/03 405.5 Nursing services
(e) (2) Quality assurance		 12/19/03
  405.6 Quality assurance program
(b)(3) Activities		  
  405.7 Patients’ rights
(b)(3) Hospital responsibilities
(b)(23) Hospital responsibilities		  
  405.11 Infection control
(b)(ii) Nosocomial surveillance, prevention and control		  
1/27/03 405.5 Nursing services
(e) Quality assurance		 5/09/03
  405.6 Quality assurance program
(b)(6) Activities		  
  405.7 Patients’ rights
(b)(3) Hospital responsibilities		  
  405.10 Medical records
(a)(1) General requirements		  

Areas Cited as a Result of Surveys:
Resident Working Hours/Enforcement

Date of Survey Type Areas Cited Date Plan of Correction Accepted
3/06/03 405.4 Medical staff
(b)(6)(ii)(d) Organization		 5/05/03
6/17/03 405.4 Medical staff
(b)(6) Organization
(b)(6)(ii)(d) Organization		 9/23/03

Most Recent Survey Date:

Areas Cited as a Result of Incident Investigations:

SOD Date Regulatory Citation Areas Cited Date Plan of Correction Accepted
none