Failure to Provide Ordered Dietary Supplement
Penalty
Summary
The facility failed to ensure that a physician's order for a dietary supplement was carried out for one resident. The resident, who had diagnoses including severe unspecified dementia with agitation, bipolar disorder, major depressive disorder, generalized muscle weakness, and dysphagia, was assessed as having severe cognitive impairment and was totally dependent on staff for eating. The resident experienced significant weight loss over a two-month period, and the care plan included a specific intervention to provide 4 ounces of ice cream daily with lunch as a nutritional supplement to address this issue. The physician's order for daily ice cream was documented in both the resident's care plan and physician orders. Despite these orders, observations and interviews revealed that the resident was not served ice cream with lunch as prescribed. The dietary card did not reflect the order for daily ice cream, and staff confirmed that the resident did not receive ice cream daily, but only on occasion. The Director of Nursing acknowledged that the order was not implemented and that the dietary card should have included the supplement. This failure resulted in the resident not receiving the prescribed nutritional intervention.