Statement of Deficiencies

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)

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 interviews, it was determined the agency failed to ensure wounds were assessed and measured weekly per policy.

This deficient practice affected 2 of 6 MR of patients with wounds including Home Visit (HV) # 5, HV # 6, and had the potential to affect all patients with wounds.

Findings include:

Agency Policy: Wound Care

Last Review and Revision: 04/2018

...Policy

2.1 Wound measurements and photos are done on ... a weekly basis...

2.4 Wound assessments and reassessments will be completed on each skilled nursing visit.

...Documentation

5.1 Document ... length, width, and depth of wound. Include location and measurements of any undermining and/or tunneling...

2. HV # 6 was admitted to the agency on 3/10/22 with diagnoses including Essential (Primary) Hypertension and Acute Embolism and Thrombosis Unspecified Deep Veins of Unspecified Lower Extremity.

Review of the HHC and POC orders dated 3/10/22 to 5/8/22 revealed a SN frequency of 1WK9 (one time per week for nine weeks)

Review of the SN VNR dated 3/16/22 revealed a new wound to the left lower calf and wound care orders implemented, but no documentation of a wound assessment or measurement.

Review of the SN VNR dated 3/22/22 revealed wound care completed to left calf using clean technique and sterile supplies per MD orders but no wound assessment or measurement was documented.

An interview conducted on 5/12/22 at 12:50 PM with EI # 9, Clinical Educator confirmed the wound was not assessed and measured per policy.

1. HV # 5 was admitted to the agency on 3/25/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System, Perforation of Intestine, and Peritoneal Abscess.

Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/25/22 revealed a Skilled Nurse (SN) frequency of 2 x a week x 2 weeks, 3 x a week x 2 weeks, then 1 x a week x 2 weeks.

Review of the SN Visit Note Reports (VNR) for the week of 4/3/22 including 4/4/22 and 4/6/22 revealed no documentation of weekly wound measurements.

In an interview conducted on 5/12/22 at 1:00 PM, Employee Identifier (EI) # 8, Registered Nurse (RN), Supervisor, confirmed wound measurements were not performed weekly per agency policy.