Failure to Administer Ordered Nutritional Supplement for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that nutritional supplements ordered for the treatment of a pressure ulcer were consistently administered to a resident with severe cognitive impairment and multiple medical diagnoses, including coronary artery disease, hypertension, and Alzheimer's disease. The resident was assessed as having increased protein needs due to a stage three pressure ulcer, and a physician's order was in place for liquid protein to be given twice daily. However, review of medication administration records revealed that the supplement was not given on eight occasions out of thirty opportunities, with several missed doses lacking documented reasons or being attributed to the supplement not being available or on order from the pharmacy. Interviews with nursing staff indicated confusion regarding the ordering and administration process for the supplement, with one LPN stating that medications were ordered electronically and should be administered upon arrival, and the ADON noting that the supplement should have been available as house stock. Despite these protocols, the supplement was not administered as ordered, and staff were unable to provide consistent explanations for the missed doses, indicating a breakdown in ensuring the resident received the prescribed nutritional intervention for pressure ulcer care.