Failure to Accommodate Resident's Vegetarian Diet Preferences
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's documented vegetarian preference and food intolerances. The resident, who was cognitively intact and independent in daily activities, had a physician's order and care plan specifying a vegetarian diet, with additional notes indicating a dislike for milk, eggs, and meat. Despite these clear dietary instructions, the resident was served meals containing meat on at least two separate occasions. On one occasion, the resident received a lunch tray with beef mixed into her rice, which led to her becoming upset and vomiting twice. The incident was documented in the nursing notes, and it was confirmed that the kitchen staff was aware of her vegetarian status. On another occasion, the resident found two pieces of chicken in her soup during dinner, which was witnessed by both a CNA and an LVN. The resident retained the chicken pieces as evidence and reported that this was not the first time such an incident had occurred. Interviews with facility staff, including the Administrator, DON, kitchen staff, and direct care staff, confirmed that the resident's vegetarian preference was known and documented on her meal tickets. The kitchen had a process for double-checking trays, and CNAs performed additional checks before distribution, but these measures failed to prevent the errors. Facility policies required that individual food preferences be assessed and accommodated, but these were not effectively implemented in this case.