| 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) |
| G0590 | Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of medical record (MR), policy and procedure and interviews, it was determined the staff failed to notify the physician with changes in the patient condition. This affected MR # 7 and MR # 3, 2 of 17 records reviewed and had the potential to affect all patients admitted to the agency. Findings include: Policy: Physician Notification and Physician Orders Review and Revision Date: 01/14 "Purpose / Objective: 1.1 To ensure that the physician is notified of all changes in patient status and that all changes... Procedure: 4.2 Reasons to obtain a New Order, or provide physician notification, will include but are not limited to the following: e. Change in patient status... i. Any parameters outside those listed above. Guidelines for Physician Notification: 7. Blood Glucose less than 70 or greater then 250... 13. Pain greater then 7..." ***** 1. MR # 7 was admitted to the agency on 5/22/18 with diagnoses including Unspecified Diastolic Heart Failure and Chronic Obstructive Pulmonary Disease. Medical record review revealed a Nurse Visit Note Report dated 6/4/18 that included documentation of the presence of a red rash beneath the patients' breasts that resembled yeast. The nurse documented use powder and keep area dry. Review of the Nurse Visit Note Report dated 6/14/18 contained documentation of trace bilateral lower extremity edema. On 6/19/18, the nurse documented a moist red rash beneath breast, treating with corn starch and baby powder mix and 3 plus bilateral lower extremity edema. There was no documentation the physician was notified regarding the worsening of the yeast-like rash and the increase in lower extremity edema. An interview was conducted on 6/28/18 at 11:57 AM with Employee Identifier (EI) # 9, Registered Nurse, Clinical Manger, who confirmed the above findings. 2. MR # 3 was admitted to the agency on 11/16/17 with a recertification date of 1/15/18 to 3/15/18 with admitting diagnoses of Type 2 Diabetes Mellitus with Chronic Kidney Disease and Chronic Kidney Disease Stage 3 Moderate. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 1/15/18 revealed the following order: Skilled nurse for observation and assessment of pain, effectiveness of pain management regimen and skilled teaching related to pain management. Skilled nurse (SN) to intervene with increased pain level to minimize complications. Review of the Guidelines for Physician Notification form revealed Pain greater than 7. Review of the Physical Therapy (PT) visit dated 1/16/18 revealed the patient reported a pain level of 8 out of 10 to the sternum. Further review revealed no documentation by PT of physician notification of pain greater then 7 and no documentation the skilled nurse was notified. Review of the Occupational Therapist (OT) note dated 1/18/18 revealed the patient reported pain in the sternum. OT failed to document the pain scale or notify the nurse or physician. Review of the SN visit dated 1/18/18 revealed the patient's random blood sugar was documented as 326. Further review of the SN note revealed the nurse documented "will notify MD" (medical doctor). Review of the Client Coordination Notes with in the MR revealed no documentation the physician was notified of the increase in blood sugar. An interview was conducted on 6/28/18 at 11:00 AM with EI # 1, Director of Nursing, who confirmed the above mentioned findings. |