Failure to Ensure Adequate Nutritional Supplementation for Underweight Resident
Penalty
Summary
The facility failed to ensure that a clinically underweight resident, who had a low Body Mass Index (BMI) and diagnoses including adult failure to thrive, received the full amount of a physician-ordered nutritional supplement. The resident was ordered to receive Med Pass 2.0, 120 ml three times daily, but was frequently only given partial doses, with documentation showing that partial amounts were administered on the majority of occasions over several months. Staff interviews revealed that when the resident refused or only partially consumed the supplement, the information was inconsistently reported to nursing staff, and there was no prompt notification to the Registered Dietitian (RD) or medical provider as required by facility policy. Observations confirmed that staff administered only 60 ml of the supplement instead of the ordered 120 ml, citing the resident's refusal to take more. Although staff were expected to document refusals and notify the appropriate clinical team members, interviews with nurses and the unit manager indicated that this process was not reliably followed. The RD and Nurse Practitioner (NP) were not made aware in a timely manner of the resident's ongoing partial consumption of the supplement, and the issue was not consistently discussed in interdisciplinary team meetings or documented in quality assurance records. The resident's weight records showed a significant weight loss over a six-month period, and care plans indicated the need for close monitoring and intervention due to the resident being far below ideal body weight. Despite these indicators and the facility's policies requiring action and communication regarding weight loss and supplement intake, the lack of timely and effective communication among staff, and the failure to follow up on partial supplement administration, resulted in the resident not receiving adequate nutritional support as ordered.