| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017025 | (X3) Date Survey Completed 05/12/2022 |
| 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) |
| G0580 | Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on review of agency policies and procedures, medical record (MR) reviews and staff interviews, it was determined the agency failed to ensure physician's orders were obtained prior to providing wound care. This deficient practice affected 1 of 6 MR's reviewed with wounds and 1 of 3 MR's reviewed with PICC (Peripherally Inserted Central Catheter) including Home Visit (HV) # 6, MR # 6, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Wound Care Revised Date 4/18 2.5 Wound care protocols are by physician orders. Agency Policy: Physician Notification and Physician Orders Date Revised: 3/18 Purpose / Objective 1.1 To ensure that the physician is notified of all changes in patient status and that all changes to the Plan of Care are addressed in a Physician Change Order and/or Coordination Note. Procedure: 4.2 Reasons to obtain a New Order, or provider physician notification, will include but are not limited to the following: c. New or Changed Wound Care Protocols. 2. MR # 6 was admitted to the agency on 4/16/22 with diagnoses including Fistula of Intestine and Other Symptoms and Signs Concerning Food and Fluid Intake. Review of the HHC and POC dated 4/16/22 revealed no orders for the care and flushing of the PICC line. Review of the VNR dated 4/16/22 revealed the nurse documented the PICC line "flushes easily". There was no documentation of what the PICC line was flushed with. In an interview conducted on 5/12/22 at 1:10 PM, EI # 10, Registered Nurse, Supervisor, confirmed there was no order on 4/16/22, the day of admission, to flush the PICC line. 1. HV # 6 was admitted to the agency on 3/10/22 with diagnoses including Essential (Primary) Hypertension and Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/10/22 to 5/8/22 revealed Skilled Nurse (SN) to observe and assess integumentary status to identify changes and intervene to minimize complications....SN to report significant changes in status to physician for early intervention. Review of the Visit Note Report (VNR) by the SN dated 3/16/22 revealed, "New wound assessed to left calf. Wound care orders implemented....Image obtained....Instructed on materials used in wound care." There was no documentation the physician was contacted to inform him/her of the new wound and obtain wound orders for care and no documentation of what wound care and supplies were used in the care of the wound. Review of the VNR by the SN dated 3/22/22 revealed, "Wound care completed to Left Calf using Clean technique and sterile supplies per MD orders". There was no documentation of physician orders for the wound care provided. An interview conducted on 5/12/22 at 12:50 PM with Employee Identifier (EI) # 9, Clinical Educator confirmed the SN provided wound care on 3/16/22 and 3/22/22 without documented physician's orders. |