Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 010001 (X3) Date Survey Completed 06/10/2016
Name of Provider or Supplier Southeast Health Medical Center Street Address, City, State 1108 Ross Clark Circle, Dothan, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0168 PATIENT RIGHTS: RESTRAINT OR SECLUSION
CFR(s): 482.13(e)(5)

The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under ยง482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law.


This STANDARD is not met as evidenced by:
Based on review of medical records (MR), facility policy and interviews with the staff it was determined the facility failed to ensure physician orders were written every 24 hours for the renewal of soft restraints for 1 of 4 MR's reviewed and affected MR # 4 and had the potential to negatively affect all patients served by the hospital. Findings include: Policy: Restraints and seclusion Utilization. Effective Date: 2/1/1980 Purpose: 1. To provide for the safety of patients, staff and others. Restraint Category: 1. Non-violent or non-self destructive behavior. Types of patients include: 1. Patients whose medical/surgical related conditions may impair the resolution of there physical problems by involuntarily disrupting life-support or other essential medical interventions (e.g., endotracheal tubes...) General Guidelines for Restraint and Seclusion: 4. ...A physician's written or verbal order should be obtained for restraint or seclusion. The order should be renewed daily according to the reason for restraint, non-violent or violent/aggressive behavior... Non-violent/Non-self-destructive Patient to Support Medical Healing: 2... Restraints for non-violent patients must be renewed/reordered daily. Continued use of restraints is authorized by the physician based upon his/her examination of the patient each calendar day. MR # 4 was admitted to the Critical Care Unit (CCU) from the Medical Surgical floor on 4/17/16 at 9:45 PM with an admitting diagnosis of Atrial Fibrillation with RVR (rapid ventricular response) and Septic Shock. Review of all the nurses notes from 4/26/16 at 4:05 PM to the time of death on 5/15/16 at 9:12 AM the patient was on a ventilator and wrist restraints were applied on 4/26/16 at 4:05 PM. Review of all the physician orders in the MR revealed there was no physician renewal orders for restraints for the following dates: 4/26/16 which was the initial dated wrist restraints were applied, 4/29/16, 4/30/16, 5/1/16, 5/2/16, 5/3/16, 5/6/16, 5/10/16 and 5/13/16. Review of the nurse note dated 4/28/16 at 10:05 AM the patient had wrist restraints on both wrists. Further review of this note revealed at 12:05 PM the nurse documented the patient had 2 wrist restraints and 2 ankle restraints on. Continues review of the nurse revealed no documentation as to why the ankle restraints were applied and review of the physician orders revealed no documentation of an order for the ankle restraints. An interview conducted on 6/10/16 at 8:30 AM with EI # 2, Quality Outcome Teamleader, confirmed physician orders were not written on a daily basis for the wrist restraints and there was no documentation of an order for the ankle restraints.