Failure to Administer Physician-Ordered Nutritional Supplement
Penalty
Summary
Nursing staff failed to follow physician dietary orders for a resident with dementia and type II diabetes who was identified as having a potential for nutritional problems. The resident's care plan included an intervention to provide an Ensure supplement as ordered, and physician orders specified Ensure Plus twice daily at 9:00 AM and 5:00 PM for protein calorie malnutrition. On the evening of 12/09/25, observation revealed that the resident was not provided the 5:00 PM Ensure Plus supplement with dinner. Interviews with staff indicated that the Ensure Plus supplement was not available on the medication cart at the time it was due. The unit manager obtained the supplement and gave it to the LPN, but the LPN confirmed that the supplement had not been administered because it was not on the cart. The LPN stated it was the nurse's responsibility to ensure the cart was stocked. The Director of Nursing stated that staff are expected to follow physician orders and administer supplements in a timely manner.