Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to process and implement dietary recommendations for nutritional supplements for three residents identified as at risk for or experiencing significant weight loss and malnutrition. For one resident, despite a registered dietician's recommendation to increase the frequency of a nutritional supplement due to ongoing weight loss, the order was not updated in the electronic medical record, and the resident continued to receive the supplement at the previous, lower frequency. This resident's weight continued to decline over several months, and staff interviews confirmed the dietary recommendation was not implemented. Two additional residents, both with documented needs for nutritional supplements due to malnutrition or increased nutritional requirements, were not served their prescribed supplements with their meals on multiple observed occasions. Meal tickets indicated the supplements were ordered, but the items were missing from their trays. Staff interviews confirmed that the kitchen was responsible for including these supplements, but they were not provided as required. The facility did not have a policy regarding nutrition or nutritional supplements at the time of the survey.