Failure to Provide Ordered Nutritional Supplement for Resident with Weight Loss
Penalty
Summary
A resident with a history of severe protein-calorie malnutrition, spinal infarction, paraplegia, stage 2 chronic kidney disease, neurogenic bowel and bladder, congestive heart failure, hypertension, atrial fibrillation, obstructive sleep apnea, coronary artery disease, and depression experienced a significant weight loss of 26 pounds (13.3%) over six months. The resident was cognitively intact and independent with eating. Despite a physician's order for a house supplement (such as Ensure or Boost) twice daily starting in late February, the resident reported not receiving the supplement for over a month and was unaware it was supposed to be provided daily. Interviews with nursing staff confirmed that the supplement was not consistently given, with one LPN admitting to not providing it that morning and an RN unable to recall the last time it was administered. Staff also indicated that the preferred flavor was sometimes unavailable, and the supplement was not always provided as ordered. The Medication Administration Record (MAR) for April showed staff, including the LPN and RN, were signing off that the supplement was given, despite the resident's statements and staff admissions that it was not consistently provided. The resident's care plan and progress notes documented the need for nutritional supplementation to address the risk of further weight loss. Facility policy required investigation and intervention for significant weight loss, but the failure to provide the ordered supplement as documented contributed to the resident's ongoing nutritional risk.