| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017025 | (X3) Date Survey Completed 04/03/2025 |
| 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 medical record (MR) review, agency policies and procedures, and interviews it was determined the agency failed to ensure: 1. Negative Pressure Wound Therapy (NPWT) black foam number removed and/or inserted into the wound was documented per policy. 2. Soiled wound VAC dressing was removed and a wound assessment completed in response to an unresolved on-call problem. 3. Blood draws from a PICC (peripherally inserted central catheter) were documented per the agency policy. 4. Wounds were measured per policy. This deficient practice affected five of 17 MRs reviewed including MR # 1, MR # 5, Home Visit (HV) # 1, HV # 3, HV # 4, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: NPWT Policy Number: Not documented Revised: 2/25 Section 1: Purpose and objective 1.1 To standardize the management of wounds where NPWT is indicated. 1.2 To ensure all patients are receiving treatment that is in keeping with best practice guidelines for wound care. ...Section 4: Procedure ...4.3 The removal of NPWT: ...Check that the number of gauze and foam pieces removed from the wound is the same as the number that was originally placed in the wound... 4.4 The application of NPWT: ...The number of pieces of foam inserted into the wound must be documented in the coordination note... Section 5: Documentation 5.1 Record application of NPWT in wound care record and coordination note. Include: ...Type and number of foam pieces removed/inserted/applied... Agency Policy: On Call Procedure Policy Number: Not documented Revised: 2/25 Section 1: Purpose/Objective 1.1 To implement, maintain, and promote Home Health...patient after hours regarding all patient related issues... Section 4: Procedure 4.1... On-call personnel will be notified for follow up on the patient to attempt to resolve the issue by phone and follow up or direct if a visit is warranted based on report and signs and symptoms. Office personnel will place an order for a scheduled visit if needed after hours to resolve any issues... Agency Policy: Wound Care Policy Number: Not documented Revised: 4/18 Section 1: Purpose and Objective 1.1 To provide and environment conductive to wound healing. 1.2 To prevent infection. 1.3 To effectively treat and document wound healing performance. Section 2: Policy 2.1 Wound measurement and photos are done on Admission...on a weekly basis... Section 5: Documentation 5.1 Document...length, width, and depth of wound... Agency Policy: PICC Line Irrigation or Blood Draw Policy Number: Not documented Revised: 2/25 Section 1: Purpose/Objective...To maintain the patency of the catheter. Section 2: Policy and Criteria. 2.1... Agency protocol is as follows: A. With 10 cc (cubic centimeter) Saline...prior to blood sampling. B. Withdrawal of blood - 10 cc and discard. C. With 20 cc Saline...after blood sample withdrawal. ...Section 4: Procedure Document procedure performed... 4. HV # 3 was admitted to the agency on 3/30/25 with a diagnose of Disruption of External Operation (surgical) Wound. Review of the HHC and POC dated 3/30/25 to 5/28/25 revealed an order for a SN frequency twice weekly for one week, and once weekly for eight weeks to perform/teach wound care to left lower back, cleanse with Normal Saline, pat dry, and leave open to air using clean/aseptic technique. Derma bond in place. Review of the SN visit note dated 3/30/25 revealed no documentation of weekly wound measurements for wound # 2, Left Mid-Back Surgical Incision (SI), and wound # 3, Medium Mid-Back SI per the agency policy. An interview was conducted on 4/3/25 at 11:15 AM with EI # 1 who confirmed wound measurements were not performed on admission per agency policy. 5. HV # 4 was admitted to the agency on 3/14/25 with a diagnosis of Encounter for Surgical Aftercare Following Surgery on the Nervous System. Review of the HHC and POC dated 3/14/25 to 5/12/25 revealed an order for SN frequency of once weekly for one week, and twice weekly for eight weeks. Review of the physician order dated 3/21/25 revealed an order for the SN to cleanse # 2 Left Axillary Surgical incision with wound cleanser/normal saline, pat dry, then leave open to air daily. Review of SN visit note dated 3/24/25 and 3/28/25 revealed no documentation of wound measurements for wound # 2, Left Axillary, Surgical Incision the week of 3/23/25 per agency policy. An interview was conducted on 4/3/25 with EI # 1 who confirmed there were no wound measurements performed weekly per agency policy. 1. MR # 1 was admitted to the agency on 3/5/25 with diagnoses including Sepsis, Unspecified Organism and Pressure Ulcer of Sacral Region, Stage 4. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/5/25 to 5/3/25 revealed an order for a skilled nurse (SN) frequency twice weekly for one week, once weekly for one week, then twice weekly for seven weeks to cleanse stage IV to sacral, pat dry, cut to fit and fill wound cavity with black foam, cover with transparent drape, apply trac pad (part of the NPWT dressing) then NPWT at 125 mmHg (millimeter of mercury) continuously on Tuesday and Friday. SN to instruct as needed NPWT protocol for malfunction including to clean with normal saline, pat dry, pack wound with Dakin's moistened gauze, cover with dry gauze, and secure with tape. Review of the two nursing notes dated 3/7/25 and 3/27/25 revealed no documentation of the number of black foam pieces removed from and placed in the sacral wound. Review of the two nursing notes dated 3/14/25 and 3/19/25 revealed no documentation of the number of black foam pieces removed from the sacral wound. Review of the On Call note dated 3/18/25 revealed the caregiver called to report the patient had a large bowel movement and the area around the NPWT and the wound was filled with stool. The cg reported there remained stool under the NPWT and the wound area after the cg had cleaned the stool off of the patient. There was no documentation the patient and/or caregiver had been educated and was able to remove the NPWT dressing, the NPWT dressing had been removed, or the agency offered an after hours SN visit to change the NPWT dressing and assessment the wound due to stool remaining under the NPWT and wound area per the caregivers report. An interview was conducted on 4/3/25 at 11:24 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to document the black foam number removed and/or inserted into the wound per policy. EI # 1 confirmed there was no documentation the NPWT dressing was removed or a SN visit was offered on 3/18/25. EI # 1 verbalized a nursing visit would have been expected by the agency with the unresolved problem of stool remaining under and around the NPWT dressing per the caregiver. 2. MR # 5 was admitted to the agency on 3/7/25 with diagnoses including Osteomyelitis of Vertebra, Lumbar Region and Intraspinal Abscess and Granuloma. Review of the HHC and POC dated 3/7/25 to 5/5/25 revealed an order for a SN frequency once weekly for eight weeks then twice weekly for one week to perform venipuncture or use PICC line to obtain a complete blood count with differential (CBC), a comprehensive metabolic panel (CMP), erythrocyte sedimentation rate (ESR), and c-reactive protein test (CRP) weekly. Review of the SN visits dated 3/10/25, 3/17/25, 3/24/25, and 3/31/25 revealed the nurse obtained the CBC, CMP, ESR, and CRP via the patient PICC line. There was no documentation the PICC line was flushed prior to or following the blood draw and 10 cc's of blood was withdrawn and discarded. An interview was conducted on 4/3/25 at 10:47 AM with EI # 1 who confirmed the agency failed to document blood draws from a PICC per the agency policy. 3. HV # 1 was admitted to the agency on 3/7/25 with diagnoses including Cerebral Infarction due to Embolism of Bilateral Carotid Arteries and Nonrheumatic Aortic (Valve) Stenosis. Review of the HHC and POC dated 3/7/25 to 5/5/25 revealed an order for a SN frequency once weekly for one week, twice weekly for two weeks, then once weekly for six weeks to perform/teach wound care to the left hand skin tear cleanse with wound cleanser, pat dry, apply silver alginate to wound bed, cover with dry gauze, wrap with rolled gauze, and secure with coban every other day. Review of two of two nursing notes for the week of 3/9/25 to 3/15/25 revealed no documentation of a wound measurement for the left hand skin tear. An interview was conducted on 4/3/25 at 10:51 AM with EI # 1 who confirmed the wound was not measured per the agency policy. |