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 08/02/2021
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)
A2400 COMPLIANCE WITH 489.24
CFR(s): 489.20(l)

[The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24.


This STANDARD is not met as evidenced by:
Based on review of the facility policies and procedures, Medical Staff Bylaws and Rules and Regulations, Southeast Health Medical Center (SH, Hospital A) Medical Record (MR) review, transferring hospital (Hospital C and Hospital D) medical record (MR), receiving hospital (Hospital B) MR, ambulance run report(s), facility Physician Link Transfer Line documentation, Physician Link Transfer Line audio files, Southeast Health Diversionary Status Report, SH Unassigned Emergency Room (ER) Call Roster(s), facility Critical Care Unit (CCU), Family Birth Center (FBC) and Neonatal Intensive Care Unit (NICU) bed census documentation, and interviews with staff it was determined the facility failed to: 1. Identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) in the facility bylaws or rules and regulations, including Patient Identifier (PI) # 23, PI # 3, PI # 4, PI # 6, PI # 11, PI # 14 and PI # 18. 2. Prevent a patient at risk for suicide from leaving the ED prior to the completion of the MSE, including PI # 15 and PI # 11. 3. Ensure the staff implemented steps to prevent a patient(s) with Suicidal Ideation (SI) from leaving prior to receiving stabilizing treatment, including placement of the patient(s) in a safe environment area, initiation of 1:1 observation and/or constant observation, and documenting every 15 minute observations of the patient(s) behavior per the facility policy, including PI # 11 and PI # 15. 4. Ensure a patient having hallucinations was re-evaluated for the dangerousness of the hallucinations and the family was apprised of the risks and benefits of leaving given the patient's hallucinations, including PI # 18. 5. Accept from referring hospitals (Hospital C and Hospital D) an appropriate transfer, of: A. PI # 2, who was experiencing a possible ST-Segment Elevation Myocardial Infarction (STEMI), and required SH 's specialized capabilities. SH had the capability and capacity to treat PI # 2, when contacted by the transferring hospital (Hospital C) which did not have the capability of treating PI # 2. B. PI # 22, who was 35 weeks pregnant and in active labor and required SH's specialized capabilities. SH had the capability and capacity to treat PI # 22, when contacted by the transferring hospital (Hospital D) which did not have the capability of treating PI #22. Findings Include: Refer to A 2406, A 2407 and A 2411 for findings.