Failure to Provide Ordered Nutritional Supplements for Weight-Stable Care
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nutritional supplements to a resident with vascular dementia and severe protein-calorie malnutrition who was experiencing significant weight loss. The resident had physician orders for fortified pudding after lunch beginning in June and frozen nutritional cups twice daily beginning in December for weight stability, and later an order for a house supplement (fortified shake) four times daily. Weight records showed a decline from approximately 154 pounds in early December to 133.8 pounds in early February, and the RD documented an 11.9% weight loss over three months. The RD and Medical Director both stated they expected the resident to receive all ordered supplements, and the RD noted the resident was usually consuming 51–75% of meals and was to receive fortified pudding once daily, house supplement three times daily, and frozen nutritional cups twice daily. Surveyor observations and staff interviews showed that the ordered fortified pudding and frozen nutritional cups were not being provided with the resident’s meals. On multiple observed lunch trays, the resident received a mechanically altered meal with nectar thick liquids but did not receive fortified pudding or a frozen nutritional cup, and a nurse aide confirmed these items were not on the lunch tray despite the resident eating about 75% of meals over the prior two weeks. Review of the meal ticket confirmed the supplements were not listed. The Dietary Manager acknowledged the resident had physician orders for fortified pudding and frozen nutritional cups and that these should have been on the tray, but stated she had no recollection of receiving a diet requisition form from nursing to add them to the Meal Tracker system. The Unit Manager could not recall whether diet requisition forms had been submitted for these supplements, and an observation of the nourishment room showed no stock of fortified pudding or frozen nutritional cups. The Medical Director, DON, and Administrator each stated they expected residents to receive nutritional supplements as ordered.
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