Statement of Deficiencies

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)

G0706

Interdisciplinary assessment of the patient
CFR(s): 484.75(b)(1)

Ongoing interdisciplinary assessment of the patient;

This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), agency policy, and staff interview(s) it was determined the SN (Skilled Nurse) failed to follow the plan of care for wound assessment(s).

This affected 2 of 6 records reviewed with wounds, including MR # 5, MR # 1 and had the potential to affect all patients served by the agency.

Findings include:

Policy: Wound Care

Date Reviewed: 4/18

"Section 2: Policy

2.1 Wound measurements and photos are done on Admission, Recertification, on a Weekly basis, and prn" (as needed)."

*****

1. MR # 5 was admitted to agency on 10/1/17 with certification dates of 10/1/17 to 11/29/17 with diagnoses including, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side.

Review of the Physician Order dated 10/14/17 revealed order for Skilled Nurse (SN) to perform/teach wound care to right and left buttocks and coccyx, using aseptic technique and sterile supplies, as follows: Cleanse with wound cleanser, pat dry, and cover with Mepilex Border. CG (Caregiver) to perform daily in absence of SNV (Skilled Nurse Visit).

Review of the SN visit notes dated 10/16/17, 10/18/17, and 10/26/17 revealed no documentation of the wound care measurements.

Based on the previous, wound measurements were not documented for the weeks of 10/15/17 thru 10/21/17 or 10/22/17 thru 10/28/17.

An interview was conducted on 6/28/18 at 11:14 AM with EI (Employee Identifier) # 10, RN supervisor, who confirmed that SN had failed to document wound care measurements per agency policy.

2. MR # 1 was admitted to the agency on 3/24/17 with diagnoses including Bacteremia, Methicillin Resistant Staph Infection, Peripheral Vascular Disease and Acquired Absence of other Right Toes.

Record review revealed a resumption of care (ROC) order dated 4/25/17 with nurse visits ordered 3 times a week for assessment of the integumentary status to identify changes, intervene and wound care to be performed to the right heel and right foot every nurse visit.

Further record review revealed plan of care updates on 4/27/17 and 5/3/17 that included changes in wound care orders and nurse visits continued 3 times a week.

Review of the Nurse Visit Note Reports dated 4/25/17, 4/26/17 and 4/28/17 failed to include documentation the nurse re-assessed wounds to the right heel and right foot and documented wound measurements.

Review of the Nurse Visit Note Reports dated 5/8/17, 5/10/17 and 5/12/17 failed to include documentation the nurse re-assessed the right heel wound and documented weekly wound measurements.

In an interview conducted on 6/28/18 at 10:39 AM, EI # 1, Director of Nursing confirmed staff failed to complete and document weekly wound measurements.