Failure to Provide Prescribed Nutritional Supplements Due to Supply Shortage
Penalty
Summary
The facility failed to ensure that prescribed nutritional supplements were available and administered as ordered for four out of six residents reviewed for nutrition. These residents had medical conditions such as diabetes, dementia, vitamin deficiencies, muscle weakness, and GERD, and had physician orders for specific supplements to address weight loss and nutritional needs. Medication Administration Records (MARs) showed multiple missed doses of supplements over several days for each resident, despite active physician orders and care plan interventions specifying the need for these supplements. Interviews with staff confirmed that the facility was out of dietary supplements for about a week due to a delivery issue related to a billing problem with the supplier. During this period, staff attempted to purchase some supplements locally but were unable to obtain all required products. Staff acknowledged that the MARs accurately reflected the missed administrations, and the administrator was aware of the shortage, which was described as lasting only a short time.