Failure to Provide Ordered Nutritional Supplement to Resident
Penalty
Summary
The facility failed to ensure that a resident with a nutritional problem received a therapeutic diet as ordered by the healthcare provider. Specifically, a female resident with a history of a right upper arm fracture and moderately impaired cognition was prescribed a regular diet with the addition of a house shake at breakfast and whole milk with dinner to support healing and optimal nutrition. Despite these orders, observations revealed that the kitchen did not have house shakes available, and the resident's breakfast tray did not include the required supplement. The resident confirmed she had not received the house shake at any point since admission. Interviews with staff indicated a lack of clarity regarding responsibility for providing the house shake, with dietary staff expected to include it on the tray and nursing staff expected to verify its presence. The registered dietitian confirmed the recommendation for the house shake and was unaware it had not been provided. The director of nursing also stated that dietary services should deliver the house shakes and that nursing should check for them before serving trays. The absence of the ordered nutritional supplement was confirmed through multiple observations and staff interviews.