Failure to Provide Ordered Nutritional Supplement to Resident with Malnutrition
Penalty
Summary
A resident with diagnoses including malnutrition, metabolic encephalopathy, muscle weakness, and cachexia was admitted to the facility with a BMI of 13, indicating extreme underweight status. The resident's care plan, initiated in early March, specified that nutritional supplements should be provided during meals according to the resident's preference. A physician order was in place for Ensure Plus to be administered three times daily as a supplement. Clinical record reviews, medication administration documentation, and direct meal observations revealed that the ordered supplement was not provided to the resident as prescribed. Specifically, there was no documented evidence that Ensure Plus was given from the date of the physician order through subsequent days, and the supplement was not present on the resident's meal trays during observed lunches. These findings were confirmed by staff interviews, including the nurse manager, registered dietitian, and director of nursing, all of whom acknowledged the lack of documentation and administration of the supplement as ordered.