Failure to Administer Ordered Nutritional Supplement
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A resident with a diagnosis of protein-calorie malnutrition and a documented decrease in albumin levels had a physician's order dated 5/29/25 for Boost nutritional supplement to be given twice daily between meals. Clinical record review revealed no evidence that the resident received the ordered supplement. Physician progress notes on 6/2/25 and 6/9/25 reiterated the need for the supplement to address ongoing malnutrition, but the provider was unaware that the supplement was not being administered as ordered. During an interview, the Director of Nursing was unable to explain how the order was missed, and it was confirmed that the resident had not received the prescribed nutritional support.