Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to follow a physician's order to provide a health shake as a nutritional supplement at lunch and dinner for a resident with diagnoses including dysphagia, rhabdomyolysis, protein-calorie malnutrition, starvation, and a sacral pressure ulcer. During meal observations on three consecutive days, the resident did not receive the prescribed health shake with lunch, despite the medication administration record indicating it had been given. Interviews with staff revealed that the kitchen was responsible for providing the health shake, while nursing staff were responsible for documenting intake, and that if the supplement was missing, the nurse should have contacted the kitchen. The facility's policy required providing nutritional supplements consistent with residents' assessed needs.