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 012513 (X3) Date Survey Completed 07/14/2021
Name of Provider or Supplier Bma Langdale Street Address, City, State 8 Medical Park North, Valley, 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 staff followed the IDT (interdisciplinary team) orders for nutrition in 2 of 4 patients with ordered LiquaCel. This affected PI (Patient Identifier) # 6 and PI # 2 and had the potential to negatively affect all patients who dialyzed at the facility. Findings include: 1. PI # 6 was admitted to the facility on 6/2/17 with diagnoses including Diabetes Mellitus with Diabetic Nephropathy and ESRD (End Stage Renal Disease). Review of the Patient Plan of Care dated 3/12/21 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 3.0 and trending down. Review of the Rounding Report printed on 7/12/21 revealed the following Albumin laboratory results: 4/28/21- 2.2 g/dL 5/26/21 - 2.3 g/dL 6/23/21 - 2.5 g/dL Review of the Current Orders Report revealed nutrition orders dated 5/31/21 for nutritional supplement, LiquaCel-1 oz (ounce) PO (by mouth) during dialysis 3 X (times) week. Review of the Treatment Sheets dated 7/7/21 and 7/12/21 for 2 of 6 treatment sheets reviewed revealed no documentation staff offered/administered LiquaCel. There was no documentation PI # 6 refused LiquaCel. An interview was conducted with EI (Employee Identifier) # 1, Director of Operations (DOO) on 7/14/21 at 12:56 PM CST (Central Standard Time) confirmed staff failed to document LiquaCel was administered as ordered. 34107 2. PI # 2 was admitted to the facility on 5/29/21 with diagnoses of Acute Kidney Injury. Review of the Patient Plan of Care dated 6/22/21 included the following nutritional goals, Albumin >=4.0 g/dL, Goal Due: 07/31/21. Open 6/8/21-Albumin 3.5. Review of the facility Lab Results Report printed on 7/12/21 revealed the following Albumin laboratory results: 6/1/21- 3.5 g/dL 6/23/21 - 2.6 g/dL Review of the Current Orders Report revealed nutrition orders dated 6/8/21 for nutritional supplement, LiquaCel-1 oz (ounce) PO during dialysis 3 X week. Review of the Treatment Sheets dated 6/26/21, 7/1/21 and 7/8/21 for 3 of 6 treatment sheets reviewed revealed no documentation staff offered/administered LiquaCel and no documentation PI # 2 refused LiquaCel. In an interview conducted on 7/14/21 at 1:20 PM CST, EI # 1 confirmed staff failed to document LiquaCel was administered as ordered.