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)
G0682 Infection Prevention
CFR(s): 484.70(a)

Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.


This STANDARD is not met as evidenced by:
Based on observations, review of agency policies and procedures, and staff interviews, it was determined the agency failed to ensure the staff:



1. Performed hand hygiene as directed per the agency policy.



2. Performed routine catheter care and perineal care according to agency policy.



This affected 4 of 7 Home Visits (HV) conducted including, HV # 4, HV # 2, HV # 3, HV # 7 and had the potential to negatively affect all patients served by this agency.



Findings include:



Policy: Hand Washing Indications

Date Reviewed: 3/18



"Section 2: Policy



2.1 All employees will follow CDC (Centers for Disease Control and Prevention) hand washing recommendations for preventing nosocomial infections.



2.2 All employees involved in patient contact/care will sanitize hands with antimicrobial containing product before and after removing gloves/ gown.



Section 4: Procedure



4.1 Employees should sanitize their hands before and after performing invasive procedures.



4.3 Employees should always sanitize their hands before and after touching wounds.



4.4 Employees should sanitize their hands before and after situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood or bodily fluids, secretions, or excretions.



4.6 Employees should sanitize their hands before and after touching inanimate sources that are likely to be contaminated virulent or infectious microorganisms..."



*****



Instructions: How to Use Hand Sanitizer

From the Purell Website:



"As with all over-the-counter products, it is important to use PURELL® Hand Sanitizer products properly and according to the instructions on the label: wet hands thoroughly with product, and briskly rub hands together until dry..."



*****



Policy: Foley Catheter Care

Date Reviewed: 3/18



"Section 1: Purpose/Objective



1.1 To promote cleanliness.

1.2 To prevent infection.

1.3 To remove odors and secretions.



Section 2: Policy



...2.2 A Home Health Aide may perform this procedure after being qualified by an R.N. (Registered Nurse).



...Section 4: Procedure



...4.2 Gently separate the labia on the female patients... Observe the urinary meatus for sores, crusts, redness, swelling, discoloration or abnormal drainage. If present, report to supervisor.



4.3 Clean the area around the urinary meatus with soapy washcloth or spray with perineal cleaning solution. Clean downward and away from the urinary meatus. Use only one downward stroke at a time. Rinse and dry. Avoid pulling on the catheter..."



*****



Policy: Perineal Care: Female

Date Reviewed: 9/13



"...Section 2: Policy and Criteria



...2.2 A Home Health Aide may perform this procedure after being qualified by a supervisor.



...Section 4: Procedure



4.6 Ask the patient to bend her knees slightly and spread her legs.



4.7 Separate the labia with one hand and wash with the other, using gentle downward strokes from front to back of the perineum to prevent internal organisms from contaminating the urethra or vagina..."



*****



1. HV # 4 was admitted to the agency on 8/10/17 and recertified from 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 Employee Identifier (EI) # 5, Aide. EI # 11, RN, was also present on the HV.



Review of the Aide Care Plan Report dated 6/13/18, revealed orders including bathing (bed/bath), routine catheter care, and perineal care every visit.



EI # 5 donned gloves to check the patient's vital signs. After examining HV # 4's arm and adjusting clothing to perform a blood pressure check, EI # 5 re-entered her/his bag to retrieve supplies, with contaminated gloves.



Each time EI # 5 removed gloves and performed hand hygiene, she/he waved hands back and forth to "dry" hands.



During the bed bath EI # 5 failed to separate the labia and clean around the meatus and urinary catheter per policy guidelines.



After completing the bed bath and emptying the bath water, EI # 5 removed her/his gloves and failed to perform hand hygiene.



EI # 5 assisted HV # 4 into wheelchair and into den area lift chair.



EI # 5 returned to patient's bedroom and changed bed linens. She/he then removed gloves and reached in to patient's glove box, without first performing hand hygiene.



While gathering up supplies to exit, EI # 5 dropped her/his personal cell phone on the floor of the bedroom. EI # 5 picked the phone up off the floor and placed on computer tablet. EI # 5 failed to clean the phone or tablet before leaving the home.



During an interview conducted on 6/28/18 at 11:30 AM with EI # 9, RN, Supervisor, the above findings were confirmed.



2. HV # 2 was admitted to the agency on 6/16/18 with diagnosis including Encounter For Other Orthopedic Aftercare and Diabetes due to Underlying Condition without Complications.



Record review revealed resumption of care (ROC) order dated 6/23/18 with a physician's order for Skilled Nurse (SN) to perform blood sugar analysis every visit...



Further review of the ROC order dated 6/23/18 revealed SN to perform wound care to lower back dehisced surgical incision, as follows: Using aseptic technique and sterile supplies cleanse with sterile Normal Saline, Pat dry, Apply skin prep to surrounding intact skin and allow to dry. Window pane wound edges with Transparent Dressing as needed (prn), then apply: Black Foam to wound bed, cut to fit... Cover with Transparent Dressing, cut hole in Transparent Dressing over Foam and attach Trac Pad.



Review of the RN (Registered Nurse) Resumption of Care Visit Note Report dated 6/23/18 revealed wound # 4 Low Back, Medial, Surgical listed for wounds.



A HV was conducted on 6/27/18 to observe care provided by EI # 3, RN. The following is the care observed during the visit:



EI # 3 obtained patient vital signs with gloves donned then obtained blood sugar using the glucometer without changing gloves or performing hand hygiene prior to obtaining blood sugar.



EI # 3 then entered nursing bag with the contaminated gloves and obtained wipes to clean equipment used during visit. After equipment was cleaned and placed in nursing bag, EI # 3 then removed contaminated gloves and performed hand hygiene.



EI # 3 then donned gloves and performed an assessment of the patient's bilateral (both) feet. Following assessment of patient's bilateral feet EI # 3 then donned 3 pairs of gloves without removing the contaminated gloves used to assess patient's feet or performing hand hygiene.



EI # 3 then documented vital signs in patient home folder, reconciled patient medication bottles with CMR (Client Medication Report) , picked up nursing bag and placed on his/her shoulder, folded wound care scissors and bag containing clean gloves in a barrier, then picked up trash used at visit in gloved hands. EI # 3 then removed the outer pair of gloves folding trash inside gloves, and placed in the trash can.



EI # 3 failed to remove the other 3 pair of gloves or perform hand hygiene following touching inanimate sources or trash removal.



EI # 3 then picked up the folded barrier and moved barrier to edge of patient bed for wound care and obtained supplies for wound vac (Vacuum-assisted closure) dressing without removing gloves or performing hand hygiene.



EI # 3 then inspected outside of the wound vac machine and removed wound drainage canister from wound vac and placed in the trash. EI # 3 then removed outer pair of gloves and placed new wound drainage canister into the wound vac.



EI # 3 failed to remove the other 2 pair of gloves or perform hand hygiene following removal of wound drainage canister or prior to the placement of new drainage canister.



EI # 3 then applied 4 clean pair of gloves over the 2 pair that were already on his/her hands.



EI # 3 failed to remove other 2 pair of gloves or perform hand hygiene prior to donning clean gloves.



EI # 3 then opened top part of gauze pad packages and moistened gauze pads with wound cleanser inside of package. EI # 3 then placed moistened gauze pad packages on barrier and removed wound vac dressing on wound # 4 and placed in the trash.



EI # 3 then placed removed wound vac dressing and outer pair of gloves in the trash. Following placement of the dressing and outer pair of gloves in the trash, EI # 3 applied hand sanitizer to remaining 5 pair of gloves that were on EI # 3's hands.



EI # 3 failed to remove other 5 pair of gloves or perform hand hygiene to bare hands after removing wound vac dressing.



EI # 3 then cleaned wound # 4 with wound cleanser moistened gauze and patted dry. EI # 3 removed outer pair of gloves and applied hand sanitizer to remaining 4 pair of gloves.



EI # 3 failed to remove other 4 pair of gloves or perform hand hygiene to bare hands.



EI # 3 then talked with caregiver for several minutes, about what to do if wound vac malfunctioned or lost power. EI # 3 asked caregiver to obtain gauze and 2 separate bottles of Normal Saline from a second wound care supply bag. EI # 3 then began to verbally instruct caregiver on how to use Normal Saline to moisten gauze for a wet to dry dressing in case of wound vac malfunction or loss of power.



EI # 3 then applied 1 clean pair of gloves over the remaining 4 pair of gloves, and demonstrated to caregiver how to apply moistened gauze into wound bed.



EI # 3 failed to remove other 4 pair of gloves or perform hand hygiene prior to demonstration of wound care to caregiver or donning new pair of gloves.



EI # 3 then obtained and opened abdominal pad from sterile package and demonstrated how to place pad over incision. EI # 3 then replaced abdominal pad back into package and placed on patient bedside table.



EI # 3 failed to remove the contaminated abdominal pad used for the demonstration to ensure it was not used for patient wound care.



EI # 3 then removed Normal Saline moistened gauze from wound bed used in demonstration, placed in the trash, and then applied a new pair of gloves over the other 5 pair of gloves.



EI # 3 failed to remove other 5 pair of gloves or perform hand hygiene prior to donning new pair of gloves.



EI # 3 then continued with wound care by placement of the wound vac transparent dressing, black foam, and Trac Pad attachment. Following the Trac Pad attachment, EI # 3 then removed outer pair of gloves and applied hand sanitizer to other 4 pair of gloves that remained on EI # 3's hands.



EI # 3 failed to remove other 4 pair of gloves or perform hand hygiene to bare hands.



EI # 3 then applied transparent dressing on top of Trac Pad to secure.



An interview was conducted with EI # 1, Director of Nursing, EI # 2, Administrator, EI #9, RN Supervisor, and EI # 10, RN Supervisor on 6/28/18 at 11:38 AM who verified the previous was improper procedure.





3. 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 Licensed Practical Nurse, EI # 4, perform wound care.



EI # 4 removed and discarded the old sacral wound dressing. EI # 4 failed to remove gloves, perform hand hygiene and don clean gloves after removal of the old (contaminated) dressing.



EI # 4 opened the wound cleanser, new gauze packets and measured the wound. EI # 4, then removed gloves, donned clean gloves, but failed to perform hand hygiene after glove removal.



EI # 4 labeled the wound measurer, placed the measurer on top of the wound and photographed the wound with wound measurer using the computer tablet camera. EI # 4 obtained a Q Tip, completed wound measurements and applied Dakins soaked gauze to the stage 4 sacral wound. EI # 4, then removed gloves and performed hand hygiene.



EI # 4 failed to remove gloves and perform hand hygiene after contact with inanimate equipment, the computer tablet for wound photography.



In an interview conducted on 6/27/18 at 3:07 PM, EI # 1, verified staff failed to follow facility infection control policy.



4. 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 after placing barriers and placing the nursing bag on the barrier, EI # 8 sanitized hands and removed all equipment from the bag and placed on the barrier. EI # 8 then sanitized hands and donned gloves and took the patient's vital signs. When complete EI # 8 removed gloves, sanitized hands and cleaned the stethoscope and placed around his/her neck. EI # 8 then donned gloves and failed to sanitize hands after cleaning of the stethoscope. EI # 8 fed patient and assessed swallowing. EI # 8 then prepared the neuromuscular unit with the same gloves on and place the electrodes on the patient's neck. EI # 8 then handed the patient the resistant breather for use and continued to wear the same gloves.



After the patient assessment and exercises were complete EI # 8 cleaned all the equipment and placed in the bag while wearing the same gloves. EI # 8 failed to remove gloves after cleaning equipment and sanitize hands prior to entering the bag.



EI # 8 then reviewed medications wearing the same gloves the equipment was cleaned with. Once the review of the medications was complete EI # 8 removed gloves and donned a clean pair of gloves without sanitizing hands and completed the visit.



An interview was conducted on 6/27/18 at 1:30 PM with EI # 1 who confirmed the above mentioned findings.