Failure to Administer Prescribed Dietary Supplement as Ordered
Penalty
Summary
A resident admitted with a diagnosis including a gallbladder fistula and identified as being at risk for weight loss and/or malnutrition was not administered a prescribed dietary supplement, Phos-Nak, as ordered by the physician. The care plan required encouraging the resident to eat, consulting with the Registered Dietitian, and following a therapeutic diet, including the administration of Phos-Nak three times daily with meals and at bedtime. Medication administration records showed that the supplement was not given for a period of nearly two weeks, with progress notes indicating the medication was unavailable and on order from the pharmacy. Nursing staff reported contacting the pharmacy to request the supplement, but it was not received, and there was uncertainty regarding follow-up actions by the responsible care manager.