Failure to Notify Physician/Dietician of Unavailable Nutritional Supplement
Penalty
Summary
The facility failed to notify the dietician or physician regarding the unavailability of an ordered nutritional supplement, Magic Cup, for two residents with significant medical needs. One resident, with diagnoses including diabetes mellitus and dementia, experienced a weight loss over three months and had a physician's order for Magic Cup twice daily. Progress notes indicated that the supplement was not available on multiple occasions due to a back order, and there was no documentation that the physician or dietician was informed of this issue. Another resident, admitted with dementia and a stage 4 pressure injury, also had an order for Magic Cup twice daily for a low BMI. Documentation showed repeated instances where the supplement was unavailable, and in some cases, Ensure was provided as a substitute without a physician's order. Staff interviews confirmed that the supplement was on back order and that appropriate notifications to the dietician or physician were not made, as required.