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 09/29/2017
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)
A0116 PATIENT RIGHTS: NOTICE OF RIGHTS
CFR(s): 482.13(a)

Patients' Rights: Notice of Rights


This STANDARD is not met as evidenced by:
Based on observation, medical record (MR) review, and interviews, it was determined the facility failed to provide a copy of the Patient's Rights on admission to the Heart and Vascular Unit. This affected 11 of 11 patients in the unit on 9/27/17, and has the potential to affect all patients served by the facility. Findings include: During a tour and review of medical records on 9/27/17 at 2:45 PM, on the Heart and Vascular Unit, revealed there was no documentation in the medical record of Patient's Rights notification. The surveyors requested a copy of the Patient's Rights provided to patients on admission. No one on the unit was able to provide a copy. An interview on 9/27/17 at 3:00 PM with Employee Identifier (EI) # 27, Registered Nurse, Clinical Director, confirmed there was no documentation in the MRs. An interview was then conducted with EI # 28, Registration Representative, who stated, "I know they are working on something to give patients," but confirmed they currently do not.