Failure to Provide Ordered Nutritional Supplement at Breakfast
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, dementia, significant weight loss, and a therapeutic diet order did not receive prescribed health shakes with breakfast as ordered by the physician. The resident had experienced a 13.5-pound weight loss over four months, and the care plan included the addition of health shakes to increase calorie intake. Despite this, observations on multiple occasions showed that the health shake was not present on the resident's breakfast tray, and the resident confirmed not receiving the supplement at breakfast. Interviews with nursing staff and a CNA revealed that the health shake order was not reflected on the resident's dietary slip for breakfast, although it was present for lunch and dinner. Staff indicated that the process for ensuring supplements are provided involves entering the order into the electronic medical record and completing a Diet Requisition and Dietician Communication Form, which should be submitted to the kitchen. However, this process was not followed for the breakfast meal, resulting in the omission of the health shake. The dietician confirmed that the recommendation for health shakes had been made due to the resident's weight loss, but the kitchen had only included the supplement for lunch and dinner, not breakfast. The failure to update the dietary slip and communicate the order to the kitchen led to the resident not receiving the prescribed nutritional supplement with breakfast, as required by the care plan and physician's order.