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 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)
G0714 Patient and caregiver education
CFR(s): 484.75(b)(5)

Patient and caregiver education;


This ELEMENT is not met as evidenced by:
Based on review of medical records (MRs), agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure patient education and return demonstration was provided for all medications and treatments. 

This deficient practice did affect four of 17 MR reviewed including MR # 6, Home Visit (HV) # 3, MR # 9, and HV # 1 and had the potential to affect all patients admitted to this agency.

Findings include:

Agency Policy: Patient/Family Education Process for Medications

Policy Number: Not Listed

Revised 10/2018

Section 1: Purpose/Objective

1.1 To provide a systematic and coordinated methodology for teaching and documenting medication instructions...

Section 4: Procedure

4.1 On admission and throughout the care stay, medication teaching will be incorporated with each assessment and care of the patient. 

4.2 Patient teaching will also include assessment of learning needs and evaluations of emotional barriers to learning...

 


4. 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. Caregiver to perform wound care every other day and as needed when soiled between nurse visits. 

Review of five of five nursing notes from 3/7/25 to 3/20/25 revealed no documentation a return demonstration was obtained from the patient and/or caregiver to ensure competency in providing wound care. 

An interview was conducted on 4/3/25 at 10:51 AM with EI # 1 who confirmed there was no documentation a return demonstration was obtained from the patient and/or caregiver to ensure competency in providing wound care. 

 

2. 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 a SN frequency twice weekly for one week, and once weekly for eight weeks to infuse Ertapenem 1 gram in 100ML via eclipse bulb every 24 hours via intravenous (IV) access to the right upper extremity (RUE) midline and SN 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. Caregiver to perform wound care daily and as needed when soiled between nurse visits.

Review of the SN visit note dated 3/30/25 and 4/1/25 revealed no documentation of return demonstration of wound care or intravenous infusion.

An interview was conducted on 4/3/25 at 11:15 AM with EI # 1 who confirmed the agency failed to ensure staff provided return demonstration of wound care or intravenous infusion.

3. MR # 9 was admitted to the agency on 10/5/24 with a diagnosis of Chronic Osteomyelitis with Draining Sinus, Left Ankle Foot.

Review of the HHC and POC dated 10/5/24 revealed a SN frequency weekly for ten weeks to infuse Vancomycin 1 gram in 250 ML via eclipse bulb over 90 minutes every 12 hours via IV access to the right upper extremity peripherally inserted central catheter. 

Review of the SN visit note dated 10/5/24 to 12/3/24 revealed no documentation of return demonstration of intravenous infusion or SN visits to infuse the Vancomycin every 12 hours.

An interview was conducted on 4/3/25 at 11:14 AM with EI # 1 who confirmed the agency failed to ensure staff provided return demonstration of intravenous infusion.

 

1. MR # 6 was admitted on 10/26/23 and recertified from 6/22/24 to 8/20/24 with diagnoses including Hypertensive Heart and Chronic Kidney Disease, Chronic Diastolic (Congestive) Heart Failure, and Type 2 Diabetes Mellitus.

Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 6/22/24 revealed physician's orders for Skilled Nurse (SN) one visit per week for eight weeks. SN for observation and assessment of pain, effectiveness of pain management and skilled teaching related to pain management. SN may instruct and reinforce medication teaching related to use of medications. 

Further review of the HHC and POC dated 6/22/24 revealed physician's orders for Tramadol 50 milligrams (mg) every eight hours as needed for pain. 

Review of the SN Visit Note Reports from 6/22/24 through 7/31/24 revealed no documentation patient teaching for the medication Tramadol was provided. 

Review of the SN Visit Note Report, Transfer to Inpatient Facility, dated 8/6/24 revealed MR # 6 was transferred to an inpatient facility due to an overdose of Tramadol. 

An interview was conducted on 4/3/25 at 10:45 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to ensure staff provided patient teaching for pain control medications.