Failure to Administer Ordered Nutritional Supplement via Feeding Tube
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a nutritional supplement ordered for a resident with severe cognitive impairment and a feeding tube was provided as prescribed. The resident, who had a diagnosis of dementia and was at risk for nutritional problems and weight fluctuations, was recommended by the dietician to receive a 2.0 cal nutritional supplement, 30cc twice daily via feeding tube. This order was confirmed by both a nurse note and a physician order. However, review of the medication/treatment administration records for the relevant period showed that the order for the nutritional supplement was not entered, and thus was not administered to the resident. Interviews with staff, including an LPN, an ACMA, the ADON, and the DON, confirmed that the supplement order was not present on the medication/treatment record and had not been given. The ADON stated that when the order was entered into the electronic clinical record, it did not carry over to the administration record. The DON acknowledged that despite daily audits of new orders, the omission of the nutritional supplement from the administration record was not identified by the charge nurse or ACMA, resulting in the resident not receiving the ordered supplement.