Failure to Provide Ordered Nutritional Supplement for Resident at Risk of Weight Loss
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, dysphagia, and acute kidney failure, who was at nutritional risk, was not provided with nutritional supplements as ordered. The resident had a physician's order for a pureed diet, nectar thick liquids, and four ounces of Gelato, a high-calorie nutritional supplement, to be given with each meal. The care plan specifically included the provision of Gelato at all meals to prevent significant weight change. However, during multiple observations, the resident's meal trays did not include the ordered Gelato, and this omission was confirmed by both nursing and dietary staff. Review of the resident's weight records showed a significant weight loss of 7.6 pounds, or 5 percent, over a three-week period. Staff interviews confirmed that the Gelato was not consistently provided as ordered, and dietary staff acknowledged the supplement was not placed on the resident's tray during at least one observed meal. This failure to provide the prescribed nutritional supplement contributed to the resident's continued weight loss, as documented in the medical record and observed by surveyors.