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 010007 (X3) Date Survey Completed 12/12/2024
Name of Provider or Supplier Mizell Memorial Hospital Street Address, City, State 702 N Main St, Opp, 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)
A0144 PATIENT RIGHTS: CARE IN SAFE SETTING
CFR(s): 482.13(c)(2)

The patient has the right to receive care in a safe setting.


This STANDARD is not met as evidenced by:
Based on observations, facility policy, and interviews, it was determined the facility failed to ensure the Senior Behavioral Care Unit (SBCU) was free of ligature risks. This deficient practice had the potential to negatively affect all patients admitted to this unit. Findings include: Facility Policy: Suicide Assessment and Preventions Policy Number: Not Listed Revised: 9/14/2017 Purpose: To outline the process for the timely assessment and reassessment of patient's suicide risk and to provide guidelines for safety interventions. Policy: It is the policy of Mizell Memorial Hospital Senior Behavioral Care Unit to create an environment of care...and successful management of patients who are at an increased risk of suicide or self destructive behaviors... Procedure: 7. Staff are to maintain a safe and therapeutic environment for all patients. Additional safety interventions are implemented for patients on suicide precautions... Remove all potential ligatures...from the environment... Safety and Environment Rounds: 1. It is the responsibility of all staff to maintain a safe and therapeutic milieu for all patients at all times. 2. Safety and Environment Rounds are to be conducted at regular intervals... 3. ... all staff are to be continually aware of the environment and immediately correct or report any identified risks, damage, ... to their supervisor or Plant Operations personnel for immediate mitigation. 1. A tour of the SBCU unit was conducted on 12/10/24 at 9:45 AM with EI # 3, SBCU Manager. The following patient safety concerns were identified: a. Each of the 14 beds on the 12 bed unit had side rails on the upper half of the beds that could be raised and used as ligature attachment. b. The faucet in the Shower Room was constructed in a manner that could allow for a ligature to be attached. Review of the daily SBCU Environmental Safety Rounds for December 2024 revealed no documentation of these safety risks being identified. An interview was conducted on 12/12/24 at 11:00 AM with EI # 3, who confirmed the side rails and the shower faucet could be used as a ligature attachment.