Failure to Accommodate Dietary Restrictions
Penalty
Summary
The facility failed to ensure that a resident was served food that accommodated their allergies and intolerances. Resident 32, who has diagnoses including dementia and chronic obstructive pulmonary disease, had a physician's order for a gluten-free, lactose-free diet effective from July 7, 2023. However, on March 31, 2025, the resident was observed consuming a cheeseburger on a regular bun, which did not comply with the dietary restrictions. During an interview, a dietary aide confirmed that the resident was mistakenly served a cheeseburger with cheese and a non-gluten-free bun. The resident's meal ticket for that lunch clearly indicated the need for a gluten-free, lactose-free diet, which was not followed. The Nursing Home Administrator acknowledged the expectation that the resident should have been served the appropriate diet and mentioned that education was provided to staff.
Plan Of Correction
1. At time of discovery, R 32 had an incident report completed, notifications and follow up was also completed as well as immediate education to E5 that served the roll and cheese. There were no adverse outcomes from a gluten free and lactose free resident eating ½ a dinner roll and cheese. 2. Education has been provided by the Dietary manager to the dietary staff on reading tray card tickets to ensure the proper diet is provided. No other residents have been identified as being served food that they may have allergies and/or intolerances to. 3. An audit will be conducted by the Dietary manager/designee on 5 patients tray cards to tray weekly x 2 weeks then monthly x 2 months to ensure that the proper diet is being sent to the resident. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.