Failure to Follow Physician's Order for Timed Supplement Administration
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order regarding the administration of a nutritional supplement for a resident with Alzheimer's disease, severe cognitive impairment, and multiple care needs. The physician's order specified that the resident was to receive one carton of Ensure by mouth 30 minutes after each meal to address protein-calorie malnutrition. However, observations on multiple occasions revealed that the Ensure supplement was provided with the resident's meal rather than 30 minutes after, as ordered. The resident was dependent on staff for most activities of daily living, including eating, and was at risk for malnutrition and weight loss. Documentation in the resident's care plan and assessments indicated the need for supervision and assistance during meals, as well as specific nutritional interventions. Despite these documented needs and orders, staff were observed leaving the supplement with the meal, and the resident consumed the Ensure during or before the meal without staff present to supervise or assist as required. Interviews with nursing and dietary staff confirmed that the expectation was to provide the supplement 30 minutes after meals, in accordance with the physician's order, to encourage meal consumption before supplement intake. The facility's policy also indicated that dietary supplementation should follow the guidance of the medical and dietician team. The failure to adhere to the specified timing of the supplement administration constituted a failure to follow the physician's order and the facility's own policy.