F0692

D

Failure to Administer and Document Ordered Nutritional Supplements

Sedalia, Missouri Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

Facility staff failed to administer and document physician-ordered nutritional supplement shakes for a cognitively intact resident. The resident’s Annual MDS indicated the resident was cognitively intact, and the Physician Order Summary contained an order for meal supplement health shakes. Review of the Medication Administration Record (MAR) for the month showed multiple dates on which there was no documentation that the ordered nutritional supplement shakes were administered as directed, including on 02/01, 02/03, 02/05, 02/07, 02/08, 02/09, 02/11–02/15, and 02/19. There was also no documentation that the resident refused the supplements on those dates.

During interviews, the administrator stated that staff are directed to document in the medical record when supplemental shakes are given or refused. The DON similarly stated that staff are to document completed medication administration, including supplemental shakes or refusals, in the medical record, and that the ADON is responsible for reviewing MARs monthly to ensure they are complete. The ADON confirmed that once medications, including supplemental shakes, are administered, staff should document this in the electronic medical record, and that he/she and the DON review MARs and TARs monthly. The ADON acknowledged that the February MARs and TARs were not checked because he/she was filling in for the MDS Coordinator and did not have time to complete the review.