Incomplete Physician Orders for Nutritional Supplements
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident, specifically regarding physician orders for nutritional supplements. The orders for a house supplement and liquid protein did not include essential information such as the route of administration and, in the case of the house supplement, the dosage. These omissions were identified during a review of the resident's medical records, which showed that the supplements were administered without the required details being documented in the orders. The resident involved was an elderly female with multiple significant diagnoses, including sepsis, mild protein-calorie malnutrition, cognitive communication deficit, dementia, chronic kidney disease, and dependence on renal dialysis. She also had a history of pressure ulcers and was at risk for malnutrition, as reflected in her care plan. The care plan included interventions for nutritional support and wound healing, which required accurate and complete physician orders for supplements. Interviews with nursing staff and facility leadership confirmed that the orders were incomplete and did not meet the facility's policy requirements, which specify that orders must include the resident's name, dosage, frequency, route, and diagnosis. Staff acknowledged that the missing information rendered the orders incomplete, although they stated that the supplements were administered as intended. The facility's policy on physician orders was reviewed and found to require the missing elements.