Statement of Deficiencies

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)

A0724

FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
CFR(s): 482.41(c)(2)

Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.

This STANDARD is not met as evidenced by:
Based on observations, review of facility policies, facility work order maintenance requests, Safety Checklist documentation, Root Cause Analysis (RCA) for the sentinel event involving Patient Identifier (PI) # 1, interviews and Facility's Corrective Action Plan submitted to the surveyors on 8/24/17, it was determined the facility failed to conduct environmental safety rounding each shift and ensure physical surroundings were safely maintained to protect patients and prevent potential harm. This has the potential to negatively affect all psychiatric patients admitted to this facility's Behavioral Medical Unit (BMU). Findings include: Facility Policy: Behavioral Medicine Risk Analysis Effective Date: 6/21/2012, Revised 8/24/17 Policy: To provide for evaluation and inspection process to provide a safe environment for patients, staff and visitors within the Behavioral Medicine Unit. Purpose: The behavioral healthcare environment demonstrates that the physical surroundings help assure that the patient cannot harm himself/herself or others, and that staff are adequately protected from potential harm of patients. To purposefully identify and eliminate environmental risks for inpatient suicide and suicide attempts, heighten the awareness of clinical staff regarding environment, environmental hazards on locked psychiatric units and to focus specific attention on psychiatric unit safety. Procedure: The Director of Behavioral Medicine will implement a proactive BMU safety program to include safety responsibility assignments, safety rounding, risk analysis. 1. Assigned BMU staff will conduct safety rounding. Any safety findings noted will be documented on the form, entered electronically into an electronic work order for review by the Safety Coordinator. The room will remain closed until inspected by staff to assure safety findings have been resolved prior to further occupancy of the room... Review of the Root Cause Analysis (RCA) dated 5/30/17 related to Patient Identifier # 1's successful suicide attempt revealed, "... Items Analyzed... Controllable environmental factors... Only identified environmental factor is the doors in patient rooms can be closed and as in this case, sheet with knot in it thrown over door and patient able to hang self... Action Required... Re-evaluate if there are other ways for doors to be in patient room so that nothing can be thrown across the top and caught when door closed, i.e. slant top of door especially in private rooms. This is being evaluated currently, no answer to what changes will be made to doors, if any... " A tour of the BHU - 3 North was conducted on 8/22/17 at 12:30 PM with Employee Identifier (EI) # 1, Director Quality Management and EI # 2, Interim Director Behavioral Health. During this tour, the surveyor observed located in the unit were 5 private rooms, including room 330. Upon entering room 330, the surveyor observed the door to the patient's bathroom had been removed. On 8/22/17 at 12:30 PM, the surveyor asked EI # 1 when the door had been removed and the reply was, "today." (8/22/17). EI # 1 stated all of the bathroom doors in the 5 private rooms had been removed on 8/22/17. During a tour of the 2 North (N) BMU (Behavioral Medical Unit) on 8/22/17 at 12:35 PM, the surveyors observed two loose hand rails with anchors visible located between the geriatric dayroom and the nurses station. During a tour of the 3 N BMU on 8/22/17 at 12:35 PM, the surveyors observed a rusted air grill (vent)in room 349, a cracked bathroom mirror in room 348, sheet rock damage with a screw visible in room 350 and peeling paint around the shower in room 342. Following the unit tours on 8/24/17 at 2:05 PM, EI # 3, Nurse Manager reported to the surveyors the safety/risk assessment rounds were completed by the Mental Health Technician's every shift. Review of the facility 3 N BMU Safety Checklist documentation provided to the surveyors failed to include May 2017 daily safety checks. There was no documentation 3 N BMU daily safety rounds were performed May 1 to May 31, 2017. Review of the 3 N BMU Safety Checklist documentation provided, revealed no daily safety checks were performed from July 6 to July 12, on July 14, and no daily safety check documentation was provided from July 17 to July 31. There was no documentation that daily safety checks were performed on 3 N BMU from August 1 to August 18, 2017. Further review of the 3 North BMU Safety Checklist documentation completed on the 3-11 shift on 6/21/17 revealed the following: "room 349 panel chip." The staff documented the discrepancy was reported to proper personnel and a work order was sent for damage. Review of the 3 North BMU Safety Checklist documentation on the 11-7 shift on 6/30, (the year was left blank) revealed "room 330 base of the bathroom sink need (s) to be pulled up closer theirs a inch gap between base and sink." There was no documentation the staff completed work order documentation for damage repair. There was no documentation the damage was repaired. On 8/23/17 at 5:26 PM, the surveyors met with administrative staff of the facility to outline the identified concerns noted above. The survey team requested a corrective action plan to address the identified concerns. On 8/24/17 at 1:45 PM, the staff provided the surveyors with the facility Corrective Action Plan documentation which included "My Maintenance Requests" printed on 8/24/17 at 11:08 AM for BMU 2 and 3 North for June and July 2017. There was no documentation repairs were completed on room 349-panel chip and room 330-bathroom sink repair. Review of the facility Corrective Action Plan documentation submitted on 8/24/17 at 7:00 PM included documentation repairs to the above observed areas were completed as of 8/24/17 at 1:45 PM with the exception of room 342's peeling paint. Review of the Corrective Action Plan documentation submitted to the surveyors on 8/24/17 at 7:00 PM revealed the following corrective actions: "... Finding 3: Safety rounds not being done consistently on 2 North (N) and 3 N BMU Nonconformity with safety rounds completed on 2 N and 3 N BMU The Organization Corrective Plan documentation outlined the following actions: August 24, 2017, review of the facility policy, Behavioral Medicine Risk Analysis, and the facility safety rounding process by the Director of Behavioral Medicine and Vice President of Patient Care Services. Policy revised. Process changed, Clinical Nurse Manager and/or Charge Nurse complete daily inspections of 2 N and 3 N BMU for any actual or potential safety concerns. Identified concerns result in immediate notification of Plant Services and Life Safety. Work order generated, room closed if determined necessary. When corrected, plant services and nursing will inspect/agree the concern was corrected, and if agreed room re-opened. August 24, 2017, education on the Daily Safety Inspection form and process for all Clinical Nurse Manager and charge nurses. August 24, 2017, Safety Officer/Safety Coordinator conduct and document monthly safety inspections using the Hazard Surveillance report, implement corrective actions. August 24-August 28, 2017, Safety Coordinator conducts education, train "the trainer" for all Clinical Nurse Manager and charge nurses. August 28, 2017, Director of Behavioral Medicine and Safety Coordinator conduct annual BMU Risk Analysis, submit report to Improving Patient Outcomes (IPO) The Interim Director of Behavioral Medicine, Vice President of Patient Care Services, Safety Coordinator is responsible for activities, implementation and adherence to the Behavioral Medicine Risk Analysis policy. August 24, 2017, Director of 2 N and 3 N BMU monitor daily (Monday-Friday, upon return from the weekend review of the weekend inspections) each units Daily Safety Inspection form, to verify daily inspections and safety concerns not corrected within 72 hours. Non-compliance result in immediate education and/or progressive discipline. Results communicated at Improving Patient Outcomes (IPO) and monthly to Continuous Survey Readiness (CSR), target 90 % with 3 consecutive month monitoring and re-evaluate monitoring status at CSR. Environmental Concerns: Door Modification: History May 30, 2017, Root Cause Analysis (RCA) initiated, identified the need to "re-evaluate doors within the patient rooms so that nothing can be thrown across the top and caught when door closed" June 8, 2017, assessment complete, follow-up action at 9:30 AM, 6 staff attended. Discussion included cutting off tops of doors, use of door alarms, roton hinges and removal of tops of doors, privacy curtains/magnetic latches across door frames. Review of 2014 Hospital and Outpatient design and construction with Life Safety consultant. August 22, 2017, all private room bathroom doors removed with evaluation of long-term plan discussion. September 1, 2017, completion date for action plan, all 2 N and 3 N BMU bathroom doors have latching mechanisms removed, replaced with a blank latching plate, preventing the doors from being securely closed. Director of Plant Services responsible. In-Visit Physical Environment Concerns: Addressed/Completed August 22, 2017, 2 N BMU: 7 bathrooms doors removed, handrails tightened, bad anchors replaced. 3 N BMU: 7 bathrooms doors removed, room 349 rusted air grill replaced, hand rails tightened, bad anchors replaced. August 23, 2017, 3 N BMU, handrails tightened, bad anchors replaced, room 348 replaced cracked mirror in bathroom, room 350 wall repairs made, replaced stained ceiling tile in soiled utility room. 2 N, In-Visit Physical Environment Concerns: Work order entered, rooms 250, 251 wood exposed/chipped formica, rooms 238, 239, 250 insulation/wallpaper ripped, room 241 cabinet wood exposed/chipped. **** Finding 6: Numerous documented patient hanging attempts during hospitalization. Cause of nonconformity was failure of BMU staff to report documented suicide attempts by hanging (Patient Identifier # 2) during hospitalization. Administration with no knowledge of the safety concern prior to August 23, 2017. The Organization Corrective Plan documentation outlined the following actions: Staff audited facility email communication (during the onsite survey visit), determined previous Director of Behavioral Medicine was aware of the safety concerns on June 10, 2017. Noncompliance with occurrence reporting identified. Quality Management completed an occurrence report, requested root cause analysis (RCA), due September 22, 2017. RCA will be presented to the Adverse Outcomes Committee, interventions implemented. In May and June 2017, the organization had one successful hanging and several attempts. Decision made to remove all latches from semi-private bathroom door on 2 N and 3 N BMU. August 22, 2017 (after surveyors entered the facility), 2 N and 3 N BMU private patient bathroom doors removed. August 25, 2017, staff "updated" on change in patient bathroom doors on 2 N and 3 N BMU. September 1, 2017, bathroom door latch removal completed. Director of Plant Services and Interim Director of Behavioral Medicine responsible for implementation. Organization follow-up: RCA interventions implemented which may result in ongoing monitoring, process to be determined.