Hospital Complaint and Survey Information - 2003
Brookhaven Hospital
PFI # 0885
Revised: 4/04
Complaint Information:
| Calendar Year: | 2003 |
|---|---|
| Complaint Investigations Completed: | 11 |
| Complaints with Statements of Deficiencies (SOD) issued: | 6 |
| % of Complaints with SODs Issued | 55% |
| Regional % of Complaints with SODs issued: | 49.2% |
Areas Cited
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| 9/11/03 | 405.7 | Patients’ rights (b) (12) Hospital responsibilities |
10/14/03 |
| 1/30/03 | 405.7 | Patients’ rights (b) (8) Hospital responsibilities |
5/9/03 |
| 8/8/03 | 405.5 | Nursing services (b) (2) (i) Delivery of services |
10/18/03 |
| 405.7 | Patients’ rights (b) (3) Hospital responsibilities |
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| 405.19 | Emergency services (c) General policies and procedures (e) (2) Patient care (f) (3) Quality assurance |
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| 3/21/03 | 405.2 | Governing body (c) (2) Compliance with laws |
7/25/03 |
| 405.3 | Administration (a) Chief executive officer |
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| 405.4 | Medical staff (c) (6) Medical staff bylaws |
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| 405.7 | Patients’ rights (b) (3) Hospital responsibilities |
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| 405.19 | Emergency services (e) (1) Patient care |
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| 6/10/03 | 405.5 | Nursing services (a) (1) Organization and staffing (a) (5)(ii) Organization and staffing (b) (1) Delivery of services (b) (1) (i) Delivery of services (b) (2) Delivery of services (e) Quality assurance |
|
| 405.6 | Quality assurance program (a) (2) (i) Quality assurance committee |
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| 405.7 | Patients’ rights (b) (3) Hospital responsibilities |
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| 405.19 | Emergency services (e) (1) Patient care (f) (3) Quality assurance |
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| 2/7/03 | 405.2 | Governing body (a) Governing body (b)(2) Organization and operation (b) (5) Organization and operation (b) (6) Organization and operation (c) (2) Compliance with laws (f) (1) Care of Patients |
8/28/03 |
| 405.3 | Administration | ||
| 405.4 | Medical staff (a) (1) (i) Medical staff accountability (a) (1) (ii) Medical staff accountability (a) (2) Medical staff accountability (c) (6) Medical staff bylaws |
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| 405.5 | Nursing services (a) (5) (ii) Organization and staffing (b) (1) Delivery of services (b) (1) (ii) Delivery of services (b) (4) Delivery of services |
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| 405.6 | Quality assurance program (a) (2) Quality assurance committee (a) (2) (i ) Quality assurance committee (a) (2) (ii) Quality assurance committee (a) (2) (iii) Quality assurance committee (a) (2) (iv) Quality assurance committee (a) (2) (v) Quality assurance committee (a) (2) (vi) Quality assurance committee (a) (2) (vii)Quality assurance committee |
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| 405.7 | Patients’ rights (b) (3) Hospital responsibilities (b) (4) Hospital responsibilities (b) (8) Hospital responsibilities (b) (23) Hospital responsibilities |
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| 405.19 | Emergency services (e) (1) Patient care (e) (2) Patient care (f) Quality assurance |
Areas Cited as a Result of Surveys: Enforcement
| Date of Survey | Type | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| 2/7/03 | 405.2 | Governing body (a) Governing body (b)(2) Organization and operation (b) (5) Organization and operation (b) (6) Organization and operation (c) (2) Compliance with laws (f) (1) Care of Patients |
8/28/03 |
| 405.3 | Administration | ||
| 405.4 | Medical staff (a) (1) (i) Medical staff accountability (a) (1) (ii) Medical staff accountability (a) (2) Medical staff accountability (c) (6) Medical staff bylaws |
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| 405.5 | Nursing services (a) (5) (ii) Organization and staffing (b) (1) Delivery of services (b) (1) (ii) Delivery of services (b) (4) Delivery of services |
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| 405.6 | Quality assurance program (a) (2) Quality assurance committee (a) (2) (i ) Quality assurance committee (a) (2) (ii) Quality assurance committee (a) (2) (iii) Quality assurance committee (a) (2) (iv) Quality assurance committee (a) (2) (v) Quality assurance committee (a) (2) (vi) Quality assurance committee (a) (2) (vii)Quality assurance committee |
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| 405.7 | Patients’ rights (b) (3) Hospital responsibilities (b) (4) Hospital responsibilities (b) (8) Hospital responsibilities (b) (23) Hospital responsibilities |
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| 405.19 | Emergency services (e) (1) Patient care (e) (2) Patient care (f) Quality assurance |
Most Recent Survey Date: NYPORTS
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| 8/18/03 | 405.8 | Incident reporting (d) The hospital shall conduct an investigation of incidents described |
10/17/03 |
| 405.21 | Maternity and newborn services (e) (4) Delivery |
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| 8/19/03 | 405.8 | Incident reporting (d) The hospital shall conduct an investigation of incidents described |
10/17/03 |
