Failure to Provide Prescribed Dietary Supplements for Wound Healing
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including a stage 4 sacral pressure ulcer, severe protein-calorie malnutrition, and dysphagia, did not receive prescribed dietary supplements intended to support wound healing. The resident's care plan and physician orders included a regular diet with mechanical soft texture and specific supplements such as fortified foods, arginaid, prostat, multivitamins, and nutritional drinks. Despite these orders, direct observation revealed that the resident did not receive fortified cereal as ordered for breakfast, and the resident reported that the food provided often did not match what was listed on the dietary ticket. Interviews with staff indicated ongoing issues with the dietary department's process for providing supplements. Certified Nurse Aides reported difficulty obtaining missing supplements from dietary staff, who sometimes refused requests due to lack of time or unavailability of items. Dietary staff admitted they did not consistently read the bottom of dietary tickets where supplements and preferences were listed, citing time constraints during meal service. The facility administrator acknowledged awareness of these issues, and the registered dietitian confirmed that all recommended supplements should have been provided as ordered.