Failure to Provide Ordered Nutritional Supplements Due to Administrative Delays and Supply Restrictions
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for four out of five residents reviewed for nutritional supplements. Multiple residents with diagnoses such as dysphagia, malnutrition, Parkinson's disease, stroke, dementia, and failure to thrive had physician orders for Medpass 2.0, a nutritional supplement, to be administered multiple times daily. Medication Administration Records (MARs) for these residents showed repeated entries indicating the supplement was unavailable on several days during the review period. Staff interviews revealed that the Dietary Manager was responsible for ordering Medpass 2.0 but faced delays in administrative approval for purchase orders, as well as restrictions on the quantity that could be ordered due to budget limitations set by administration. These delays and restrictions resulted in insufficient supply and the supplement being unavailable for residents on multiple days. Nursing staff confirmed the supplement was often unavailable, and attempts to locate additional supply within the facility were unsuccessful. Residents and staff confirmed that the prescribed nutritional supplements were not received as ordered on the documented dates. The Director of Nursing Services (DNS) verified that the '9' notation on the MAR indicated the supplement was not available and confirmed the missed doses for each affected resident. The lack of timely administrative approval and supply limitations directly led to the failure to provide the ordered nutritional supplements.