Failure to Provide Physician-Ordered Nutritional Supplement with Meals
Penalty
Summary
A deficiency occurred when the facility failed to follow the physician's order for a resident who was to receive Boost VHC, a very high-calorie nutritional supplement, three times daily with meals. The resident, who had diagnoses including myocardial infarction, dementia, and immunodeficiency, experienced significant weight loss over several months. The Order Summary Diet Order, dated July 18, 2025, specified the need for Boost VHC with meals, as recommended by the Registered Dietitian due to the resident's poor meal intake and ongoing weight loss. During direct meal observations on two separate occasions, the resident did not receive the ordered Boost VHC with either lunch or breakfast. Staff interviews and record reviews confirmed that the supplement was not provided and that there was no documentation of its intake. The facility's policy required the provision of nutritional supplements according to assessed needs, but this was not followed for the resident in question.