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 012500 (X3) Date Survey Completed 09/16/2021
Name of Provider or Supplier Fmc Capitol City Street Address, City, State 255 South Jackson Street, Montgomery, 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)
V0545 POC-EFFECTIVE NUTRITIONAL STATUS
CFR(s): 494.90(a)(2)

The interdisciplinary team must provide the necessary care and counseling services to achieve and sustain an effective nutritional status. A patient's albumin level and body weight must be measured at least monthly. Additional evidence-based professionally-accepted clinical nutrition indicators may be monitored, as appropriate.


This STANDARD is not met as evidenced by:
Based on medical record (MR) review and interview with the staff, it was determined the facility failed to ensure: 1. The IDT (interdisciplinary team) followed the patient Plan of Care (POC) for albumin management, monitored monthly nutrition labs and addressed the nutrition needs with a rapid decline in the albumin level. 2. The staff administered nutritional supplementation as ordered. This affected PI (Patient Identifier) # 5 and PI # 1 in 2 of 10 records reviewed and had the potential to negatively affect all patients who dialyzed at the facility. Findings include: 1. PI # 5 was admitted to the facility on 7/3/19 with diagnoses including Diabetes Mellitus with Diabetic Nephropathy and ESRD (End Stage Renal Disease). Review of the Patient POC dated 4/29/21 included the following nutritional goals, Albumin >= (greater than equal to) 4.0 g/dL (gram/deciliter); Goal Due: 09/30/21. Open 03/22/21-Albumin 3.9-intervention monitor albumin and other nutrition related labs monthly. Review of the Rounding Report printed on 7/12/21 revealed the following Albumin laboratory results: 7//07/21- 3.8 g/dL 8/04/21 4.0 g/dL 9/01/21 - 3.1 g/dL Review of the Treatment Sheets dated 9/6/21, 9/8/21, 9/10/21, and 9/13/21 revealed no documentation nutritional supplementation was provided for the declining albumin level. There was no physician's order for nutritional supplementation to address the 9/1/21 3.1 albumin level. An interview was conducted with EI (Employee Identifier) # 2, Director of Operations on 9//16//21 at 9:19 AM who confirmed the IDT failed to follow the 4/29/21 POC, monitor the monthly labs and provide nutritional supplementation to address the albumin level less than 4.0. g/DL. 2. PI # 1 was admitted to the facility 7/24/21 with diagnoses including ESRD. Review of the Orders Summary Report revealed physician orders dated 8/10/21 for the nutritional supplement, Liquacel -1 ounce by mouth every dialysis treatment. Review of the 8/28/21 Treatment Sheet revealed the Albumin laboratory result was 2.8 g/dL on 8/5/21. There was no documentation Liquacel was provided and no documentation the patient refused Liquacel on 8/28/21. An interview was conducted on 9/16/21 at 9:02 AM with EI # 1, Clinic Manager who confirmed there was no documentation of the Liquacel was administered as ordered.