Failure to Provide Ordered Nutritional Supplement to High-Risk Resident
Penalty
Summary
A resident with a history of stroke, bladder cancer, difficulty swallowing, pressure ulcer, and malnutrition was re-admitted to the facility following multiple hospitalizations and was identified as being at nutritional risk. The resident had significant cognitive impairment and required 1:1 assistance during meals, as well as a physician order for a house supplement (health shake) to be provided twice daily with lunch and dinner. The care plan and dietary orders reflected these needs, and the resident had experienced significant weight loss during recent hospitalizations. On the day of observation, the resident did not receive their dinner tray at the same time as other residents, and when the tray was eventually delivered, it was missing the ordered health shake supplement. The RN assigned to the resident was unaware of the missing supplement until prompted and had to leave the room to retrieve it. Interviews with staff, including the RN, Unit Manager, Dietary Manager, and DON, revealed that the process for ensuring residents received their prescribed supplements was not consistently followed. The dietary staff missed including the supplement due to a recent diet change and being rushed, and there was a lack of double-checking by both kitchen and floor staff. Facility policy required a systematic approach to maintaining residents' nutritional status, including assessment, individualized care planning, and consistent implementation and monitoring of interventions. However, the failure to provide the ordered nutritional supplement as part of the resident's meal demonstrated a breakdown in these processes, as staff did not ensure the supplement was delivered as ordered, despite the resident's high nutritional risk and need for assistance.