Failure to Provide Ordered Nutritional Supplement for Resident with Significant Weight Loss
Penalty
Summary
A resident with a history of dysphagia following a cerebral infarction was readmitted to the facility and had physician's orders for a very high calorie nutritional supplement (Boost VHC) to be provided with meals, as well as participation in a restorative nursing assistant (RNA) dining program. Multiple observations over several days revealed that the resident was not provided with the ordered Boost supplement during meals, despite significant weight loss documented in the medical record. Staff interviews confirmed that the Boost was not given, and the process for obtaining the supplement involved CNAs retrieving it from the medication cart, which did not occur. The resident's weight dropped from 103 lbs to 91 lbs over approximately one month, and the registered dietician's notes indicated underweight status and weight below goal. The registered dietician and the DON both stated that the Boost supplement was an important intervention for the resident's nutritional needs and that staff were expected to follow physician's orders. Facility policy required the identification and provision of adequate food and fluids to maintain sufficient nutrition and hydration, as well as monitoring and documentation of dietary intake. Despite these policies and the resident's significant weight loss, the ordered nutritional supplement was not provided, and the dietician was unaware of this omission until the time of the survey.