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 10/05/2017
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)
K0933 Features of Fire Protection - Fire Loss Preve
CFR(s): NFPA 101

Features of Fire Protection - Fire Loss Prevention in Operating Rooms Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers: * packaging is non-flammable * applicators are in unit doses * Preoperative "time-out" is conducted prior the initiation of any surgical procedure to verify: o application site is dry prior to draping and use of surgical equipment o pooling of solution has not occurred or has been corrected o solution-soaked materials have been removed from the OR prior to draping and use of surgical devices o policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99)


This STANDARD is not met as evidenced by:
. Based on review of documentation and interview, the building failed to provide documentation of procedures and continuing education the administration provides for "fire loss prevention in operating rooms." per the requirements of: 2012 NFPA 99, 15.13 Findings include: On 10/04/2017, during the review of documentation from 8:00 am to 5:00 pm, the building failed to provide documentation of procedures and continuing education the administration provides for "fire loss prevention in operating rooms." A member of the maintenance staff was present, when this deficiency was identified.