Failure to Assess and Provide Ordered Nutritional Supplement
Penalty
Summary
A resident who appeared thin and frail was not provided with their ordered nutritional supplement drink during lunch on multiple occasions. Observations showed that the resident's meal tray included juice and Lactaid milk, but not the prescribed supplement. Staff interviews revealed that the resident's meal ticket did not list the supplement, and the dietary staff prepared meals based on these tickets. The dietician confirmed that she was responsible for assessing residents' nutritional needs and that dietary communication slips were used to inform the kitchen of required supplements. However, the resident's dietary evaluation was not completed following both their initial admission and subsequent readmission, resulting in the supplement order not being entered into the dietary system or reflected on the meal ticket. Record review indicated that the resident's dietary evaluation form and nutritional care plan remained incomplete, and there was no documentation of an assessment of the resident's nutritional needs. The order for the supplement drink was present in the medical record, but it was not communicated to the dietary staff via the required forms or the electronic system. Facility policy required a nutritional assessment within 24-72 hours of admission and communication of supplement orders to the kitchen, but these procedures were not followed, leading to the resident not receiving the ordered nutritional supplement.