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 11/06/2020
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)
A0000 An abbreviated on site survey was conducted 10/13/2020 to 11/06/2020 at Southeast Health Medical Center to investigate complaint number AL00040222. The complaint was substantiated and standard level deficiencies were written. In addition, a COVID-19 Focused Infection Control survey was conducted. Medical record review revealed the facility failed to follow its own policies and procedures for skin and wound management. This included prevention interventions such as turning every two hours for pressure relief, skin assessments each shift, implementation of the wound care order set when skin lesions are identified and notifying the physician of wounds and wound changes. The deficiency was identified in 4 of 5 records reviewed from five different patient care units. During the survey, interviews with direct care staff as well as management staff revealed the facility had recognized improvement was needed in skin and wound management. The facility Skin Defense Team identified 2 improvement measures, Universal Turns and Turn Teams. The new measures were piloted on one unit in June 2020, then implemented on additional patient care units with completion to all patient care unity expected by November 12, 2020. The new measures include Universal Turns - all patients are turned on a set rotation schedule to a set site (8:00 AM right side, 10:00 AM left side, 12:00 PM supine). Turn Teams - at the beginning of each shift the charge nurse assigns 2 staff members to each 2 hour interval to turn all the patients on the unit that require turning. The assigned team is responsible for documenting each turn both in the medical record and on the turn assignment sheet. Compliance monitoring measures include verification of completion each shift by the charge nurse, weekly audits of the medical record and the assignment sheet by the unit manager, monthly prevalence study of Every 2 Hour Turns by management, and monthly Wound Management audits. The audit results reported by the Skin Defense Team demonstrate improvement as exampled below: Every 2 Hour Turns: October 2019 - compliance 68%; September 2020 - compliance 90% ; and Fiscal Year to Date Average 79% Overall Wound Management: October 2019 - compliance 46% ; September 2020 - compliance 84%; and Fiscal Year to Date Average - 75% See A 0392 for findings.