Hospital Complaint and Survey Information - 2003
WESTCHESTER MEDICAL CENTER
PFI # 1139
Revised: August 2004
Complaint Information:
| Calendar Year: | 2003 |
|---|---|
| Complaint Investigations Completed: | 30 |
| Complaints with Statements of Deficiencies (SOD) issued: | 5 |
| % of Complaints with SODs Issued | 16.7% |
| Regional % of Complaints with SODs issued: | 24.5% |
Areas Cited as a Result of Complaint Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 1/17/2003 | 405.2(f)(1) | Governing Body-Care of Patients | Pending |
| 1/17/2003 | 405.4(a)(1)(i) | Medical Staff-Medical Staff Accountability | |
| 1/17/2003 | 405.5(b)(1)(i)(ii)(iii)(4) | Nursing Services-Delivery of Services | |
| 1/17/2003 | 405.17(a)(7)(ii)(8) | Pharmaceutical Services | |
| 3/20/03 | 405.2(f)(1) | Governing Body-Care of patients | 1/9/04 |
| 3/20/03 | 405.4(a)(1)(i) | Medical Staff-Medical staff accountability | 1/9/04 |
| 8/7/03 | 405.10(a)(1) | Medical Records-General Requirements | 10/23/03 |
| 8/14/03 | 405.2(a) | Governing Body | 11/5/03 |
| 8/14/03 | 405.4(a)(1)(i) | Medical Staff-Medical staff accountability | 11/5/03 |
| 8/14/03 | 405.10 | Medical Records | 11/5/03 |
| 11/21/03 | 405.4(a)(1)(i) | Medical Staff | 8/11/04 |
| 11/21/03 | 405.5(b)(3)(4) | Nursing Services-Delivery of Services | 8/11/04 |
| 11/21/03 | 405.5(c) | Nursing Services-Administration of Drugs | 8/11/04 |
| 11/21/03 | 405.15(a)(3) | Radiologic and Nuclear Medicine Services | 8/11/04 |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 9/26/03 | Title 18 | 405.2136 GB: Health & Safety | Pending |
| 9/26/03 | Title 18 | 405.2136(b) Revised Opearational Objectives | Pending |
| 9/26/03 | Title 18 | 405.2136(d)(2) Personnel P/P; Safe and Sanitary Environment | Pending |
| 9/26/03 | Title 18 | 405.2136(d)(2) Personnel P/P: Health Exams | Pending |
| 9/26/03 | Title 18 | 405.2136(f)(1)(ix) Pt. Care Policies: Physical Plant | Pending |
| 9/26/03 | Title 18 | 405.2137(a)(1) Long Term Plan Team Members | Pending |
| 9/26/03 | Title 18 | 405.2137(b)(1) PCP: Individualized | Pending |
| 9/26/03 | Title 18 | 405.2138 PT R/R: Staff Trained | Pending |
| 9/26/03 | Title 18 | 405.2138(c) Respect, Dignity & Privacy | Pending |
| 9/26/03 | Title 18 | 405.2139(a) Med Rec: PT Assessments | Pending |
| 9/26/03 | Title 18 | 405.2139(a) Med Rec: D/C Summary | Pending |
| 9/26/03 | Title 18 | 405.2140(a) PE: Constr & Maintain for Safety | Pending |
| 9/26/03 | Title 18 | 405.2140(a)(2) PE: Equipment PM | Pending |
| 9/26/03 | Title 18 | 405.2140(a)(3) PE: Free of Hazards | Pending |
| 9/26/03 | Title 18 | 405.2140(a)(5)(ii) AAMI-Chem Contam | Pending |
| 9/26/03 | Title 18 | 405.2140(b)(1) PE: Infection Control | Pending |
| 9/26/03 | Title 18 | 405.2140(c) Prevent Cross Contamination | Pending |
| 9/26/03 | Title 18 | 405.2140(d)(1) ER: Written Plan | Pending |
Most Recent Survey Date:
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 9/9/03 | 405.2(a) | Governing Body | Pending |
| 9/9/03 | 405.2(f)(1) | Governing Body - Care of patients | Pending |
| 9/9/03 | 405.4(a)(1)(i) | Medical Staff -Medical staff accountability | Pending |
| 9/9/03 | 405.5(b)(1)(ii)(b)(2) | Nursing Services-Delivery of services | Pending |
| 9/9/03 | 405.8(a) | Incident Reporting | Pending |
| 9/9/03 | 405.19(c)(2) | Emergency Services - Patient Care | Pending |
