Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to follow physician orders to provide prescribed nutritional supplements to a resident with non-Alzheimer's dementia who was on a weight-gain regimen. The resident had a history of weight fluctuations and was considered at increased nutrition and hydration risk, requiring a mechanically altered diet. Physician orders specified a 4-ounce nutritional shake three times daily with meals and a frozen nutritional treat twice daily. Despite these orders, direct observations on two separate days showed that the resident did not receive the ordered supplements with her lunch meal. Meal tickets indicated the supplements were to be provided, but they were absent from the meal trays. Interviews with the Dietary Manager and Registered Dietitian confirmed that supplements should have been provided as ordered. The Dietary Manager was unable to explain why the supplements were missing, and the Registered Dietitian noted that even though the order for the frozen nutritional treat was discontinued on one of the days, the meal tray tickets had not been updated in the dietary computer system. Staff were still expected to provide items as listed on the tray tickets. The responsible dietary aide was unavailable for interview, and the administrator stated that all residents should receive nutritional supplements as ordered.