Hospital Complaint and Survey Information - 2003
Faxton - St. Luke's Healthcare — St. Luke’s Division
PFI # 0599
Revised: 2/04
Complaint Information:
| Calendar Year: | 2003 |
|---|---|
| Complaint Investigations Completed: | 3 |
| Complaints with Statements of Deficiencies (SOD) issued: | 2 |
| % of Complaints with SODs Issued | 67% |
| Regional % of Complaints with SODs issued: | 38.9% |
Areas Cited
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| 5/7/2003 | 405.2(b) | Governing Body - Organization & Operation | 8/19/2003 |
| 405.10(b) | Medical Records - Content | ||
| 405.10(c) | Medical Records - Authentication | ||
| 405.11(b) | Infection Control - Nosocomial Surveillance, Prevention and Control | ||
| 405.11(d) | Infection Control — Integration with the Quality Assurance Program | ||
| 405.11(e) | Infection Control - Infection Control Education | ||
| 9/25/2003 | 405.2(b) | Governing Body - Organization & Operation | 11/17/2003 |
| 405.5(b) | Nursing Services - Delivery of Services | ||
| 405.5(e) | Nursing Services - Quality Assurance | ||
| 405.6(a) | Quality Assurance | ||
| 405.7(b) | Patients' Rights - Hospital Responsibilities | ||
| 405.10(c) | Medical Records - Authentication | ||
| 405.11(b) | Infection Control - Nosocomial Surveillance, Prevention and Control | ||
| 405.11(d) | Infection Control - Integration with the Quality Assurance Program | ||
| 405.14(d) | Respiratory Care Services — Operation & Service Delivery |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| 2/4/2003 | Annual Compliance Review - Resident Work Hours | None | |
| 10/14 - 16/2003 | Article 28 Compliance & Medicare ESRD Recert - Oneida Dialysis Unit | 405.2136(c) - Governing Body & Management - CEO: Staff Train | 1/29/2004 |
| 405.2136(d) - Governing Body & Management - Personnel P/P: Safe and Sanitary Environment | |||
| 405.2136(f) - Governing Body & Management - Patient Care Policies - RX Services | |||
| 410.2140(a) - Physical Environment - Constr & Maintain for Safety | |||
| 405.2140(a) - Physical Environment - PE: Equipment PM | |||
| 405.2140(d) - Physical Environment - ER: Periodic Drills | |||
| 405.2140(d) - Physical Environment - ER: Patients Informed | |||
| 405.2163(f) - Minimal Service Requirements - Participation in Recipient Registry | |||
| 757.1(a) - Chronic Renal Dialysis Services - Chronic Renal Dialysis Services |
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| none | |||
