Hospital Complaint and Survey Information - 2003
St. Catherine of Medical Center
PFI # 0943
Revised: 4/04
Complaint Information:
| Calendar Year: | 2003 |
|---|---|
| Complaint Investigations Completed: | 13 |
| Complaints with Statements of Deficiencies (SOD) issued: | 8 |
| % of Complaints with SODs Issued | 62% |
| Regional % of Complaints with SODs issued: | 49.2% |
Areas Cited
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| 1/30/03 | 405.9 | Admission/discharge (b) (12) Admission |
NO POC REQUIRED |
| 10/11/02 | 405.4 | Medical staff (a) (1) (i) Medical staff accountability |
3/11/03 |
| 405.6 | Quality assurance program (a) (2) Quality assurance committee |
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| 405.7 | Patients’ rights (b) (4) Hospital responsibilities |
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| 405.19 | Emergency services (b) (1) (i) Organization |
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| 3/11/03 | 405.7 | Patients’ rights (b) (3) Hospital responsibilities |
NO POC REQUIRED |
| 10/7/03 | 405.6 | Quality assurance program (a) (2) (i) Quality assurance committee |
11/07/03 |
| 405.7 | Patients’ rights (b) (3) Hospital responsibilities |
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| 405.11 | Infection control (b) ( i) Nosocomial surveillance, prevention and control (b) (ii) Nosocomial surveillance, prevention and control (d) Integration with the quality assurance program |
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| 405.21 | Maternity and newborn services (c) (6) General requirements |
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| 10/07/03 | 405.5 | Nursing services (c) Administration of drugs |
11/07/03 |
| 405.7 | Patients’ rights (b) (23) Hospital responsibilities |
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| 405.24 | Environmental health (e) Housekeeping |
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| 5/19/03 | 405.5 | Nursing services (b) (1) Delivery of services |
8/15/03 |
| 405.11 | Infection control (e) Infection control education |
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| 405.16 | Laboratory services (b) (14) Laboratory shall make provision for the proper receipt and reporting of tissue specimens |
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| 5/19/03 | 405.4 | Medical staff (a) (1) (i)Medical staff accountability (b) (2) Organization |
12/09/03 |
| 405.12 | Surgical services | ||
| 10/07/03 | 405.5 | Nursing services (c) Administration of drugs |
11/07/03 |
| 405.6 | Quality assurance program (a) (2) (i) Quality assurance committee |
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| 405.7 | Patients’ rights (b) (3) Hospital responsibilities (b) (13) Hospital responsibilities (b) (23) Hospital responsibilities |
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| 405.11 | Infection control (b) (i) Nosocomial surveillance, prevention and control (b) (ii) Nosocomial surveillance, prevention and control (d) Integration with the quality assurance program |
||
| 405.21 | Maternity and newborn services (c) (6) General requirements |
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| 405.24 | Environmental health (e) Housekeeping |
Areas Cited as a Result of Surveys: Article 28
| Date of Survey | Type | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| 1/17/03 | 405.1 | Introduction | 2/11/03 |
| 405.7 | Patients’ rights (b) (3) Hospital responsibilities |
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| 405.10 | Medical records (a) (3) General requirements (b) (2) (vi) Content (c) (1) Authentication |
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| 405.11 | Infection Control (e) Education |
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| 405.24 | Environmental health (e) (1) Housekeeping |
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| 711 | General standards of construction | ||
| 711.2 | Pertinent technical standards (a) (1) NFPA 101-1997 Life safety code (a) (26) NFPA 99-1996 Standard for Health Care Facilities (c) Design standard for the disabled (ADA) |
Most Recent Survey Date:
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| none | |||
