Failure to Provide Physician‑Ordered Nutritional Supplement at Lunch
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered nutritional supplement to a resident with identified nutritional concerns. The resident, who had diagnoses including Ogilvie syndrome, hemiplegia and hemiparesis following a cerebral infarction, had a comprehensive care plan focus area for "state of nourishment, less than body requirement" characterized by weight loss, inadequate intake, and decreased appetite, with interventions that included providing therapeutic supplements. The consolidated physician orders included an order for Ensure Clear with the noon/lunch meal once daily. Despite this, observation of the resident’s lunch tray showed no supplement present, and the resident reported that he was supposed to receive a supplement at lunch but that staff never gave it to him. The resident’s responsible party reported that the resident was not receiving his Ensure Clear as ordered and stated she had raised this concern at the last two care plan meetings, including one documented meeting where the care plan noted the need for clear Ensure. The social worker confirmed remembering the family’s report about the Ensure Clear and stated she believed she had passed the information on to nursing but did not follow up to ensure the supplement was provided. The DON stated she was not aware the resident was not receiving the ordered supplement and indicated there was no reason the supplement should not have been provided if ordered. The facility’s provided policy on administering medication stated that medications are to be administered in a safe and timely manner and as prescribed, but the resident’s ordered supplement was not administered with his lunch as required.
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