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)
G0710 Provide services in the plan of care
CFR(s): 484.75(b)(3)

Providing services that are ordered by the physician as indicated in the plan of care;


This ELEMENT is not met as evidenced by:
Based on observations, review of medical records (MR), review of agency policy, and staff interviews, it was determined the agency failed to ensure the staff:



1. Obtained weekly weights prescribed by the physician.



2. Performed wound care as prescribed by the physician.



3. Obtained blood sugar analysis each visit as prescribed by the physician.



This affected MR # 1, MR # 3, MR # 4, MR # 6 and Home Visit (HV) # 2, 5 of 17 records reviewed and had the potential to affect all patients served byt this agency.



Findings include:



Policy: Wound Care

Date Reviewed: 4/18



"Section 2: Policy



2.5 Wound care protocols are by physician orders."



Policy: Oasis Based Admission and Resumption of Care Assessments

Date Revised 5/18



"Section 1: Purpose/Objective



1.1 To implement and maintain a process that preserves a systematic and coordinated plan for the course of care for all patients/clients of the Agency.



Secton 4: Procedure



4.8 The weight and blood sugar log will be assessed every SNV (Skilled Nurse Visit) and document on SN Note, if applicable."



*****



1. 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 resumption of care (ROC) orders dated 4/25/17 with nurse visits ordered 3 times a week, patient to be weighed weekly, report weight gain of 5 lbs (pounds) in one week to the medical doctor.



Review of the Nurse Visit Note Reports dated 4/25/17, 4/26/17 and 4/28/17 failed to contain documentation weekly weights were obtained.



Review of the Nurse Visit Note Reports dated 5/8/17, 5/10/17 and 5/12/17 failed to contain documentation weekly weights were obtained.



Review of the Nurse Visit Note Reports dated 5/15/17, 5/17/17 and 5/19/17 failed to contain documentation weekly weights were obtained.



In an interview conducted on 6/28/18 at 10:39 AM, Employee Identifier (EI) # 1, Director of Nursing confirmed staff failed to document weekly weights the weeks of 4/23/17, 5/7/17 and 5/14/17 as ordered in the plan of care.

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 for wound care:



SN to perform wound care to anterior outer edge of right foot diabetic ulcer (#4) as follows: Using clean technique and sterile supplies, cleanse with wound cleanser or Normal Saline, pat dry, cover with foam border dressing...



Review of the physician order dated 1/18/18 at 4:19 PM revealed the following order: Skilled nurse to provide wound care to right lateral foot ulcer using aseptic technique and sterile supplies as follows: Cleanse with wound cleanser, pat dry, apply silver foam border. Change Monday / Thursday, PRN (as needed). Instruct caregiver to change between skilled nurse visits.



Review of the SNV dated 1/18/18 at 11:15 AM revealed the following wound documentation, "skilled nurse to provided wound care to ulceration on right outer foot using aseptic techniques and sterile supplies. Cleansed with wound cleanser or sterile saline, patted dry, covered with Mepilex Silver AG foam border gauze during SNV..."



Review of the nurse visit note revealed no documentation as to which solution the nurse cleaned the wound with and the skilled nurse also used Mepilex AG foam border gauze and the order stated border gauze not the Mepilex AG.



An interview was conducted on 6/28/18 at 11:00 AM with EI # 1 who confirmed the above mentioned findings.



3. MR # 4 was admitted to the agency on 4/13/18 and recertified from 6/12/17 to 8/10/17. Admitting diagnoses included Type 2 Diabetes Mellitus without complications and Essential (Primary) Hypertension.



Review of the HHC and POC revealed orders for the SN to perform blood sugar analysis every visit... SN to weigh patient each visit and report weight loss of 3 lbs (pounds) or more per month to MD (Medical Doctor).



Review of the SN Visit Note dated 6/16/17 revealed no documented blood sugar or weight.



Review of the SN Visit Notes dated 6/22/17, 6/28/17, 7/4/17, and 7/12/17 revealed no documented weight.



During an interview on 6/28/18 at 11:20 AM with EI # 10, RN, Supervisor, the above findings were confirmed.



4. MR # 6 was admitted to the agency on 6/5/18, diagnoses included Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Chronic Respiratory Failure with Hypoxia



Review of the HHC and POC dated 6/5/18 to 8/3/18, revealed a physician order for SN to weigh patient every SN visit and instruct patient to weigh every morning after first void and record on weight log.



Review of the Nurse Visit Note Report dated 6/8/18, revealed documentation in the narrative section of "Wt (weight) 2 days ago 125. No scales in home. Advised to obtain scales."



Further review of Nurse visit Note report dated 6/8/18 revealed no documentation that SN had documented a patient weight obtained at the SN visit.



Review of the Nurse Visit Note Report dated 6/15/18 failed to contain documentation of the patient's weight at visit or assessment of the patient's weight log.



During an interview conducted on 6/28/18 at 11:51 AM with EI # 10, RN Supervisor, the above findings were confirmed.



5. 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) orders dated 6/23/18 with a physician's order for 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 Resumption of Care Visit Note Report dated 6/23/18 revealed wound # 4 Low Back, Medial, Surgical listed for wounds.



Review of the MR revealed no documentation that physician was contacted to clarify the wound name or wound number.



An observation visit was conducted on 6/27/18 at 1:00 PM to observe wound care provided to HV # 2. The following wound care was observed during visit by surveyor:



EI # 3 moistened gauze pads with wound cleanser and cleansed wound # 4.



EI # 3 then cut wound vac transparent dressing into strips and applied to wound edges to form window pane.



EI # 3 failed to cleanse wound # 4 with Normal Saline or apply skin prep to surrounding intact skin and allow it to dry prior to application of transparent dressing window pane.



Review of the RN visit note report dated 6/27/18 revealed wound care documentation under narrative section as follows: Wound care to # 1 (incorrectly documented, should have been # 4) lower back dehisced surgical incision using aseptic technique and sterile supplies....Cleansed with wound cleanser and sterile gauze, patted dry, no skin prep needed at this time.



Review of the visit note report revealed no documentation that the physician was notified about use of wound cleanser to clean the wound instead of Normal Saline or skin prep not applied to surrounding intact skin.



An interview was conducted with EI # 1, Director of Nursing, on 6/28/18 at 12:30 AM for notification of the previous findings.