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 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)
G0576 All orders recorded in plan of care
CFR(s): 484.60(a)(3)

All patient care orders, including verbal orders, must be recorded in the plan of care.


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR) and interview with the staff it was determined the agency failed to ensure staff documented all physician orders and entered them into the patient medical record. This affected 1 of 2 unsampled patients reviewed from the agency's complaint log, and did affect Unsampled Patient #1, and had the potential to negatively affect all patients served by the agency.



Findings include:



1. Unsampled Patient # 1 was admitted to the agency on 12/27/17 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System.



Review of the agency complaint log revealed the following documentation dated 1/10/18 at 3:56 PM: "The daughter of the patient, ... voiced a complaint that neither the nurse aides or nurses had taken proper care of her dad, resulting in the sore and infection that he now has on the end of his penis."



Review of the MR revealed an On Call Client Coordination Note dated 1/2/18. The SN documented: "...On call visit due to patient going to Urologist and having catheter removed with no output for over 8 hours. ...On Call MD (Medical Doctor) contacted regarding urine retention and orders received to reinsert catheter..."



A copy of the MD order to reinsert catheter was requested by the surveyor. Employee Identifier (EI) # 1, Director of Nursing, responded in an email dated 6/29/18 at 11:42 AM to the surveyor there was no order written for the catheter.