Hospital Information 2004
North Shore University Hospital
PFI # 0541
Revised: 6/05
Complaints:
| Complaint Information: | 2004 |
|---|---|
| Complaint Investigations Completed: | 28 |
| Complaints with Statements of Deficiencies (SOD) issued: | 14 |
| % of Complaints with SODs Issued | 50% |
| Regional % of Complaints with SODs issued: | 41.4% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 3/15/04 | 405.24(e)(1) | Environmental Health
Housekeeping |
4/14/04 |
| 2/4/04 | 405.4(a)(1)(i) | Medical Staff
Medical Staff Accountability |
5/5/04 |
| 405.5(b)(4) | Nursing Services
Delivery of Services |
||
| 405.7(b)(14 | Patients' Rights
Hospital Responsibilities |
||
| 4/15/04 | 405.5(b)(3) | Nursing Services
Delivery of Services |
NO POC REQUIRED |
| 405.5(b)(4) | Nursing Services
Delivery of Services |
||
| 405.5(c) | Nursing Services
Administration of Drugs |
||
| 405.7(b)(3) | Patients' Rights
Hospital Responsibilities |
||
| 10/14/04 | 405.4(a)(1)(i) | Medical Staff
Medical Staff Accountability |
NO POC REQUIRED |
| 405.7(b)(3) | Patients' Rights
Hospital Responsibilities |
||
| 5/21/04 | 405.2(b)(2) | Governing Body
Organization and Operation |
5/24/05 |
| 405.2(f)(1) | Governing Body
Care of Patients |
||
| 405.4(a)(1)(i) | Medical Staff
Medical Staff Accountability |
||
| 405.4(a)(1)(ii) | Medical Staff
Medical Staff Accountability |
||
| 405.7(b)(14) | Patients' Rights
Hospital Responsibilities |
||
| 9/20/04 | 405.7(b)(24) | Patients' Rights
Hospital Responsibilities |
10/19/04 |
| 405.10(b)(2)(vi) | Medical Records
Content |
||
| 405.15(a)(5) | Radiologic and Nuclear Medicine Services
General Provisions for Diagnostic and Therapeutic Radiologic Services |
||
| 4/19/04 | 405.10(b)(2)(vi) | Medical Records
Content |
9/23/04 |
| 1/29/04 | 405.5(c) | Nursing Services
Administration of Drugs |
4/6/04 |
| 405.5(e)(1) | Nursing Services
Quality Assurance |
||
| 7/1/04 | 405.24(e)(1) | Environmental Health
Housekeeping |
NO POC REQUIRED |
| 5/25/04 | 405.4(f)(3)(ii) | Medical Staff
Postgraduate Trainees |
8/12/04 |
| 405.4(i) | Medical Staff
Autopsies |
||
| 405.16(c)(2)(ii) | Laboratory Services
Personnel |
||
| 10/28/04 | 405.5(b)(1) | Nursing Services
Delivery of Services |
12/9/04 |
| 405.5(b)(4) | Nursing Services
Delivery of Services |
||
| 405.16 | Laboratory Services | ||
| 405.23(b)(5) | Food and Dietetic Services
Organization |
||
| 1/24/05 | 405.5(b)(4) | Nursing Services
Delivery of Services |
4/20/05 |
| 405.5(c)(1) | Nursing Services
Administration of Drugs |
||
| 405.6(b)(5) | Quality Assurance Program
Activities |
||
| 405.7(b)(3) | Patients' Rights
Hospital Responsibilities |
||
| 405.10(a)(3) | Medical Records
General Requirements |
||
| 405.10(b)(2)(vii) | Medical Records
Content |
||
| 3/30/05 | 711.4(aa)(7) | General Structural Equip & Safety Standards
Mechanical Requirements |
7/1/05 |
| 4/22/05 | 405.19(e)(2) | Emergency Services
Patient Care |
6/27/05 |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 7/14/04 | 405.11(b)(1) | Infection Control
Nosocomial Surveillance, Prevention and Control |
11/23/04 |
Most Recent Survey Date:
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 7/29/04 | 405.8(d)(4) | Incident Reporting | 8/30/04 |
| 1/3/05 | 405.8(a) | Incident Reporting | 2/1/05 |
