Hospital Name: MERCY HOSPITAL
PFI # 0213
Complaints:
| Complaint Information: | 2000 |
| Complaint Investigations Completed | 22 |
| Complaints with Statements of Deficiencies (SOD) Issued | 8 |
| % of Complaints with SODs Issued | 36% |
| Regional % of Complaints with SODs Issued | 40.6% |
Areas
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
| 12/29/00 | 405.6 | Quality Assurance QA | 2/2/01 |
| 12/29/00 | 405.5 | Nursing Services Delivery of Services | 2/2/01 |
| 12/29/00 | 405.4 | Medical Staff Medical Staff Accountability | 2/2/01 |
| 9/20/00 | 405.9 | Admission/Discharge Admission | 10/11/00 |
| 9/20/00 | 405.5 | Nursing Services Delivery of Services | 10/11/00 |
| 9/20/00 | 405.19 | Emergency Services General | 10/11/00 |
| 8/14/00 | 405.7 | Patients' Rights Hospital Responsibilities | 8/14/00 |
| 5/15/00 | 405.5 | Nursing Services Delivery of Services | 5/15/00 |
| 5/12/00 | 405.9 | Admission/Discharge Discharge | 5/31/00 |
| 5/5/00 | 405.6 | Quality Assurance Program Committee Activities | 6/19/00 |
| 5/5/00 | 405.5 | Nursing Services Delivery of Services | 6/19/00 |
| 5/5/00 | 405.4 | Medical Staff Medical Staff Accountability | 6/19/00 |
| 3/3/00 | 405.9 | Admission/Discharge Discharge | 5/2/00 |
| 3/3/00 | 405.19 | Emergency Services Patient | 5/2/00 |
| 2/7/00 | 405.7 | Patients' Rights Hospital Responsibilities | 2/24/00 |
| 2/7/00 | 405.5 | Nursing Services Delivery of Services | 2/24/00 |
| 2/7/00 | 405.4 | Medical Staff Medical Staff Accountability | 2/24/00 |
Areas Cited as a Result of
Surveys:
| DATE OF SURVEY | TYPE | Areas Cited: | Date Plan of Correction Accepted |
| 6/7/00 - 6/13/00 | Validation | 482.55(b) - Emergency Services Personnel | 6/26/00 |
| 6/7/00 - 6/13/00 | Validation | 482.52(b) - Anesthesia Delivery of Services | 6/26/00 |
| 6/7/00 - 6/13/00 | Validation | 482.41(b) - Physical Environment Life Safety from Fire | 6/26/00 |
| 6/7/00 - 6/13/00 | Validation | 482.21 - Quality Assurance Clinical Plan | 6/26/00 |
| 6/7/00 - 6/13/00 | Validation | 482.23 - Nursing Services Staffing & Delivery of Care | 6/26/00 |
| 6/7/00 - 6/13/00 | Validation | 482.24 - Medical Record Services Content of Record | 6/26/00 |
INCIDENTS
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
| 12/19/00 | 405.6 | Quality Assurance QA Committee | 3/27/01 |