Failure to Provide Ordered Nutritional Supplement Drink
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including toxic encephalopathy, sepsis, and pneumonia, was readmitted to the facility and had physician orders for a regular, pureed diet with thin consistency, as well as a nutritional supplement drink to be provided with breakfast and lunch. The resident's care plan and nutritional assessment both specified the need for the supplement drink twice daily to provide additional calories and protein. However, during an observation of the resident's lunch, the nutritional supplement drink was not present on the meal tray. Interviews with dietary and nursing staff revealed that the kitchen does not provide the supplement drinks, and it is the responsibility of nursing staff to administer them. Both the certified nursing assistant and restorative nursing assistant who assisted the resident with meals confirmed that the supplement drink was not provided at breakfast or lunch. The DON acknowledged that the supplement should have been given as per the physician's order. The facility's policy states that therapeutic diets are to be provided according to physician orders and care plans.