Cortland Memorial Hospital

PFI # 0158

Revised: 4/03

Complaints:

Complaint Information: 2002
Complaint Investigations Completed: 3
Complaints with Statements of Deficiencies (SOD) issued: 2
% of Complaints with SODs Issued 67%
Regional % of Complaints with SODs issued: 33.8%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
05/28/2002 405.7(b) Patients' Rights - Hospital Responsibilities 9/23/02

405.11(e) Infection Control - Infection Control Education

  405.17(a) Pharmaceutical Services - Organization & Direction  
06/28/2002 400.21(a) HIV Infection Control 8/29/2002
  405.6 Quality Assurance  
       

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
7/30/2002 Allegation Follow up SOD Issued by Centers for Medicare & Medicaid Services Plan of Correction Accepted by Centers for Medicare & Medicaid Services
       

Areas Cited as a Result of Incident Investigations:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
04/17/2002 405.2(f) Governing Body - Care of Patients 7/23/2002
  405.4(a) Medical Staff - Medical Staff Accountability  
  405.6(a) Quality Assurance  
  405.6(b) Quality Assurance  
  405.8(c) Incident Reporting  
  405.10(b) Medical Records - Content