| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017025 | (X3) Date Survey Completed 06/28/2018 |
| Name of Provider or Supplier Saad Enterprises, Inc. | Street Address, City, State 1515 University Blvd, South, Mobile, 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) |
| G0536 | A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on review of agency policy, medical records (MR), observations and interviews, it was determined the agency failed to ensure the Client Medication Report (CMR) was accurate and reflected all current medications. This affected 6 of 17 records reviewed, including Home Visit(s) (HV) # 5, HV # 4, HV # 1, HV # 3, HV # 7, HV # 6 and had the potential to negatively affect all patients admitted to this agency. Findings include: Policy: Medication Profile Process Date Reviewed: 4/2018 "Section 2: Policy 2.1 A Plan of Care with Medication Profile will be completed on every patient upon admission to the agency and verified with physician for accuracy. Skilled Nurse and Therapy will reconcile medications every visit and as needed for medication changes. Section 5: Documentation 5.1 Documentation on the Plan of Care and Medication Profile must be clear, concise and accurate." ***** 1. HV # 5 was admitted to the agency on 5/25/18 with admitting diagnoses including Cervicalgia, and Type 2 Diabetes with Diabetic Neuropathy. A HV was conducted on 6/27/18 at 8:45 AM to observe care provided by Employee Identifier (EI) # 6, Occupational Therapist (OT). EI # 11, RN (Registered Nurse) was also present on the HV. During the HV, the medications in the home were compared to the CMR provided to the surveyor. The following discrepancy was observed: Prorenal Oral 8 mg, one tablet daily, was listed on the CMR. HV # 5 stated that was incorrect, he/she took two tablets daily. During an interview on 6/28/18 at 10:45 AM with EI # 1, Director of Nursing, the above findings were confirmed. 2. HV # 4 was admitted to the agency on 8/11/17 and recertified 6/7/18 to 8/5/18. Admitting diagnoses included Encounter for Fitting and Adjustment of Urinary Device, and Other Neuromuscular Dysfunction of Bladder. A HV was conducted on 6/27/18 at 9:40 AM to observe care provided by EI # 5, Aide. EI # 11 was also present on the HV. During the HV, the medications in the home were compared to the CMR dated 6/7/18 to 8/5/18 and provided to the surveyor. The following discrepancies were observed: a). Clonazepam 0.5 mg, 1 tablet by mouth twice daily as needed for anxiety, was in the home and not on the CMR. The date filled was 5/3/18. b). Clearlax 3350, as needed for constipation, was in the home and not on the CMR. The patient's caregiver stated that HV # 4 had "...used that for a long time." c). Antifungal Powder, as needed to skin under the breasts, was in the home and not on the CMR. The date filled was 4/18/18. During an interview conducted on 6/28/18 at 11:30 AM with EI # 9, RN, Supervisor, the above findings were confirmed. 3. HV # 1 was admitted to the agency on 1/31/18 and recertified for continued care on 5/31/18 to 7/29/18 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side, Essential Hypertension, Type 2 Diabetes and Long Term Use of Insulin. A home visit was conducted on 6/26/18 at 1:20 PM to observe the Medical Social Worker, EI # 12. The surveyor compared medications found in the home with the CMR provided to the surveyor on 6/26/18. Found in the home was Vancyclovir 1 gram orally daily, filled on 5/21/18. The Vancyclovir was not documented on the current CMR. The patient reported Levimir U-100 dosage 55 U (units) every (Q) morning (AM) and 40 U Q PM (evening) in use greater than 1 month. The CMP documented Levemir U 100 20 units Q AM and 14 U Q PM. During an interview conducted on 6/28/18 at 10:56 AM, EI # 1 confirmed the CMR was not accurate for the patients current medications. 4. HV # 3 was admitted to the agency on 8/22/16 and recertified for continued care on 6/13/18 to 8/11/18 with diagnoses including Pressure Ulcer of Sacral Region, Stage 4. A home visit was conducted on 6/27/18 at 1:15 PM to observe the Licensed Practical Nurse, EI # 4, perform wound care. The surveyor compared medications found in the home with the CMR provided to the surveyor on 6/27/18. Found in the home was Methadone 10 mg 3 tablets two times a day (BID), filled on 6/14/18. Methadone 10 mg 2 tablets BID was documented on the current CMR. Documented on the CMR was Sodium Bicarbonate 650 mg oral 1 tablet BID and Vitamin B 12 oral 1,000 microgram 1 tablet daily. No Sodium Bicarbonate and Vitamin B 12 was found in the home and the caregiver confirmed the medications were not being taken. In an interview conducted on 6/28/18 at 10:50 AM, EI # 9, Registered Nurse, Clinical Manager verified staff failed to maintain a current/updated CMR for HV # 3. 5. HV # 7 was admitted to the agency on 1/9/18 with a recertification date of 5/9/18 to 7/7/18 and admitting diagnoses of Parkinson's Disease and Dysphagia Unspecified. A HV was conducted on 6/27/18 at 10:30 AM with EI # 8, Speech Therapist, to observe care provided. During the HV the patient's medications were reviewed with the caregiver using the patient's medication bottles and the CMR provided to the surveyor by the agency. The following medications were in the home and not listed on the CMR: Celebrex 200 mg by mouth every 12 hours as needed bottle dated 4/21/11 when the prescription began. Oxybutynin 5 mg/ml (milliters) 1 teaspoon twice a day bottle dated 6/19/18 the day perscription began. The following medications were listed on the CMR and the patient was no longer taking: Fesoterodine 8 mg 1 tablet daily discontinued 6/19/18 Nutren 2.0 feeding tube 0.08 gram - 2 kcal (kilocalorie's)/ml 3-4 cans daily discontinued 5/18. Lisinopril 20 mg daily (bottle dosage was 10 mg) discontinued 5/18. The following medication was listed on the CMR incorrectly according the the bottle directions: Primidone 50 mg 1 tablet 2 times a day was on the CMR. Bottle directions were written as Primidone 50 mg 1 - 3 tablets daily date started was unknown. An interview was conducted on 6/27/18 at 1:30 PM with EI # 1 who confirmed the above mentioned findings. 6. HV # 6 was admitted to the agency on 6/7/18 with admitting diagnoses of Aftercare Following Joint Replacement Surgery and Essential Primary Hypertension. A HV was conducted on 6/27/18 at 11:45 AM with EI # 7, Physical Therapist, to observe care provided. During the HV the patient's medications were reviewed with the patient using the patient's medication bottles and the CMR provided to the surveyor by the agency. The following medication was listed on the CMR and patient stated he/she was no longer taking the medications. The patient stated he/she stopped the medication 1 1/2 to 2 weeks ago. Senokot 8.6 mg 1 tablet daily. An interview was conducted on 6/28/18 at 10:55 AM with EI # 1 who confirmed the above mentioned findings. |