Failure to Provide Ordered Nutritional Supplement with Meals
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of unspecified protein calorie malnutrition was not provided with a physician-ordered frozen nutritional supplement during a lunch meal. The resident had a severely impaired cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of one out of 15. Review of the resident's electronic medical record confirmed an active order for the supplement to be given with meals. During observation, the lunch tray did not include the supplement, and the resident was only offered a meal plate, iced tea, and Italian ice. The resident's family member confirmed the absence of the supplement and noted that the resident had previously received and enjoyed it. Interviews with facility staff revealed that the dietary department was out of the frozen nutritional supplement and was awaiting a new supply from their food supplier. The Director of Dietary (DOD) was unaware that the supplement was to be given with meals, mistakenly believing it was to be provided between meals. The registered dietitian confirmed the supply issue and stated that the resident had previously refused liquid supplements, but no alternative, such as regular ice cream, was offered during the shortage. The facility's policy required providing nutritional supplements consistent with assessed needs, but this was not followed in this instance.