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 08/24/2017
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)
A0115 PATIENT RIGHTS
CFR(s): 482.13

A hospital must protect and promote each patient's rights.


This CONDITION is not met as evidenced by:
Based on observations, review of facility policies, Facility Scope of Care Behavioral Health Services (BHS) / Behavioral Medicine Unit (BMU), facility work order maintenance requests, Safety Checklist documentation, security video footage, Root Cause Analysis (RCA), medical records, interviews and Facility's Corrective Action Plan submitted to the surveyors on 8/24/17, it was determined the facility failed to: 1. Ensure psychiatric patients were provided care in a safe environment. 2. Ensure Mental Health Technicians (MHTs) performed patient safety rounds every 15 minutes. 3. Ensure Licensed nursing staff performed patient rounds every hour. 4. Recognize the complexity of Patient Identifier (PI) #1's previous suicide attempts, including the attempt to self violence in the facility's Emergency Department (ED) and place the patient on 1:1 observation. 5. Ensure a treatment plan was implemented and updated for a suicidal patient to provide safe care and environment for PI # 1. 6. The BMU staff recognized PI # 2's self-destructive behaviors while in the BMU, PI # 2 was free from harm related to those self-destructive behaviors and placed the patient on 1:1 observation. 7. PI # 2's right to be free of restraint was not violated by placing the patient in a geri-chair (cardiac chair) for greater than 15 hours after being found trying to harm him/herself. 8. Conduct environmental safety rounding each shift and ensure physical surroundings were safely maintained to protect patients and prevent potential harm. This affected 2 of 3 medical records reviewed, including PI # 1, PI # 2 and has the potential to negatively affect all psychiatric patients admitted to this facility's BMU. Findings include: Refer to A144 and A154 for findings.