South Nassau Communities Hospital

PFI # 0527

Revised: 3/02

Complaints:

Complaint Information: 2001
Complaint Investigations Completed: 15
Complaints with Statements of Deficiencies (SOD) issued: 10
% of Complaints with SODs Issued 66%
Regional % of Complaints with SODs issued: 54.3%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
9/17/01 405.4 Medical staff (a) Medical staff accountability 12/19/01
  405.5 Nursing services (b) Delivery of services (c) Administration of drugs (e) Quality assurance  
  405.6 Quality assurance program (b) Activities of the quality assurance committee  
  405.7 Patients’ rights (b) Hospital responsibilities  
  405.8 Incident reporting (b) Incident to be reported  
8/06/01 405.7 Patients’ rights (b) Hospital responsibilities 9/19/01
  405.19 Emergency services (e) Patient care (f) Quality assurance  
8/07/01 405.4 Medical staff (a) Medical staff accountability 10/13/01
  405.5 Nursing services (b) Delivery of services  
  405.6 Quality assurance program (b) Activities of the quality assurance committee  
  405.7 Patients’ rights (b) Hospital responsibilities  
  406.3 Admission, patient assessment, planning and services  
5/23/01 405.4 Medical staff (a) Medical staff accountability   6/15/01
  405.7 Patients’ rights (b) Hospital responsibilities  
12/05/00 405.4 Medical staff (a) Medical staff accountability 2/20/01
9/12/01 405.6 Quality assurance program (b) Activities of the quality assurance program 10/16/01
  405.7 Patients’ rights (b) Hospital responsibilities  
  405.19 Emergency services (e) Patient care (f) Quality assurance  
5/23/01 405.7 Patients’ rights (b) Hospital responsibilities NO POC NEEDED
1/16/01 405.7 Patients’ rights (b) Hospital responsibilities 6/14/01
  405.8 Incident reporting (a) Incident to be reported  
  405.10 Medical records (a) General requirements  
9/12/01 405.5 Nursing services (b) Delivery of services 10/23/01
  405.7 Patients’ rights (b) Hospital responsibilities  
  405.24 Environmental Health (f) Linen and Laundry  
10/31/01 405.2 Governing body (c) Compliance with Federal, State, and local laws (d) Chief executive officer NO POC NEEDED
  405.3 Administration (a) Chief executive officer  
  405.5 Nursing services (b) Delivery of services  
  405.7 Patients’ rights (b) Hospital responsibilities  

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
       

Most Recent Survey Date:

Areas Cited as a Result of Incident Investigations:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
1/26/01 405.4 Medical staff (a) Medical staff accountability (c) Medical staff bylaws 3/16/01
  405.6 Quality assurance program (a) Governing body  
  405.9 Admission/discharge (f) Discharge  
  405.10 Medical records (b) Content