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)
G0716 Preparing clinical notes
CFR(s): 484.75(b)(6)

Preparing clinical notes;


This ELEMENT is not met as evidenced by:
Based on review of agency policy, medical record (MR) and interview, it was determined the agency staff failed to ensure medical record documentation was complete and included the specific wound care performed. This affected 1 of 6 records reviewed with wounds including MR # 1 and had the potential to affect all patients admitted to this agency.



Finding include:



Policy Title: Wound Documentation

Revised 8/13



"Section 2: Policy



2.1 Wound documentation should be clear using verbiage...universally accepted.



2.2 Wound documentation should be concise.



...2.4 Wound documentation should accurately reflect the actual status of the patient at the time of the procedure.



Section 5: Documentation



5.1 The documentation on the procedure performed for wound care should be incorporated in the notes to describe the wound care protocol...



5.3 Document the exact wound care procedure performed during the visit..."



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 to cleanse the right heel pressure ulcer with normal saline or wound cleanser, apply Aquacel, cover with foam dressing. Nurse visits were ordered 3 times a week for 4 weeks.



Review of the ROC Nurse Visit Reports dated 4/25/17 and 4/26/17 failed to reveal the specific cleansing solution used during wound care, whether wound cleanser or normal saline was used to the right heel for wound cleansing.



Physican orders dated 4/27/17 and 5/3/17 included cleanse right heel with wound cleanser or normal saline, pat dry, leave open to air.



Review of the Nurse Visit Reports dated 4/28/17, 5/1/17, 5/3/17, 5/5/17, 5/8/17, 5/10/17 and 5/12/17 failed to contain documentation for the specific cleansing solution, whether wound cleanser or normal saline was used to the right heel during wound care.



In an interview conducted on 6/28/18 at 10:39 AM, Employee Identifier (EI) # 1, Director of Nursing confirmed staff failed document the exact wound care procedure performed during nurse visits.