Unauthorized Administration of Nutritional Supplement Without Documented Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services provided matched physician orders and met professional standards, specifically regarding administration of a nutritional house supplement. Resident #2 was admitted with chronic combined systolic and diastolic congestive heart failure, type 2 diabetes mellitus with circulatory complications, vitamin deficiency, and generalized muscle weakness. Review of the resident’s clinical record on 03/16/2026 showed no current physician order for a house supplement. An LPN reported that on 03/09/2026 she notified the nurse practitioner that the resident was not eating, and she received a verbal order to administer 4 ounces of house supplement whenever the resident refused meals. She admitted she forgot to enter this verbal order into the record and stated she administered the supplement at least four times between 03/09/2026 and 03/16/2026, but could not recall the specific dates or times. She confirmed she should not have administered the supplement without entering the order. The nurse practitioner confirmed she had given a verbal order the prior week for the house supplement to be given if the resident refused to eat and would accept it, and stated that if the supplement was administered, it should have been entered as an order. Another LPN, assigned to the resident from 6:00 a.m. to 6:00 p.m. on 03/17/2026, stated she administered 4 ounces of the house supplement that morning with the resident’s medications, then confirmed upon review of the record that there was no order for the supplement and expressed uncertainty about whether she should have given it without an order. The DON reviewed the clinical record and confirmed there was no documented evidence that the house supplement had been ordered for the resident and acknowledged that nurses should not have administered the supplement without an order in the clinical record.
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