Failure to Administer Physician-Ordered Therapeutic Supplements Due to Lack of Clarification
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including cerebral infarction, type 2 diabetes, protein-calorie malnutrition, hypertension, anemia, peripheral vascular disease, and end stage renal disease on dialysis, was not administered prescribed therapeutic dietary supplements. The resident had documented risk factors for malnutrition, as evidenced by a low BMI and nutritional assessments indicating risk, and was ordered a renal diet with liquid protein and Nepro supplements by the physician. These orders were clearly documented in the resident's care plan and medication administration records (MAR). Despite the physician's orders, the resident did not receive the liquid protein and Nepro supplements on multiple occasions. Medication administration notes repeatedly indicated that certified medication aides (CMAs) did not administer the supplements due to needing clarification on the type or quantity of supplement to give. The CMAs documented their need for clarification and reported notifying nurses, but there was no evidence that clarification was obtained or that the supplements were subsequently administered as ordered. The MAR reflected numerous missed doses over several weeks. Interviews with the CMAs confirmed that they withheld administration of the supplements pending clarification, and that they notified nurses but were unsure if clarification was ever received. The Director of Nursing (DON) acknowledged that the lack of follow-up or miscommunication led to the failure to administer the supplements as ordered. There was no specific policy in place for how CMAs should escalate clarification needs to nurses and physicians, contributing to the ongoing issue.