Failure to Provide Prescribed Nutritional Supplements to Resident with Weight Loss
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and diabetes, who had experienced significant weight loss, did not receive prescribed nutritional supplements as ordered by the physician and recommended by the Registered Dietitian (RD). The resident had active orders for daily ice cream and a nutritional shake to be added to the lunch tray to prevent further weight loss. Despite these orders being clearly documented and included on the meal ticket, observations on two consecutive days revealed that neither the ice cream nor the nutritional shake were present on the resident's lunch tray. Interviews with dietary staff confirmed that the supplements were omitted due to oversight during meal tray preparation. The resident's medical record showed a notable decline in weight over several months, with the RD documenting a 10.9% weight loss over 159 days and emphasizing the need for the supplements to meet nutritional requirements. The care plan identified the resident's nutritional risk and included interventions to maintain adequate nutritional status. Both the RD and the Nurse Practitioner confirmed that the supplements were necessary and should have been provided as ordered. The dietary department, including aides and supervisors, acknowledged responsibility for ensuring supplements were added to trays but failed to do so, resulting in the deficiency.