Hospital Name: St. James Mercy*

PFI # 0870

Complaints:

Complaint Information: 2002
Complaint Investigations Completed 3
Complaints with Statements of Deficiencies (SOD) Issued 1
% of Complaints with SODs Issued 33%
Regional % of Complaints with SODs Issued 28.6%

Areas Cited:

SOD Date Regulatory Citation Areas Cited Date Plan of Correction Accepted
7/24/2002 405.6 QA PROGRAM QA COMMITTEE 9/24/02
7/24/2002 405.19 EMERGENCY SERVICES- PATIENT CARE 9/24/02

Areas Cited as a Result of Surveys:

DATE OF SURVEY TYPE Areas Cited: Date Plan of Correction Accepted
7/15/2002 - 7/16/2002 TITLE 18 A409 - RESTRICTING TRANSFER UNTIL PT STAB 9/24/02
7/15/2002 - 7/16/2002 TITLE 18 A406 - SPECIAL RESPONSIBILITIES/MEDICARE HOSPITAL 9/24/02
7/15/2002 - 7/16/2002 TITLE 18 A405 - MUST KEEP A CENTRAL LOG ON INDIVIDUALS 9/24/02
7/15/2002 - 7/16/2002 TITLE 18 A400 - HOSPITAL AGREES TO COMPLY WITH 489.24B 9/24/02

INCIDENTS

Areas Cited:

SOD Date Regulatory Citation Areas Cited Date Plan of Correction Accepted
9/9/2002 405.2 GOVERNING BODY CARE OF PATIENTS 9/26/02