Failure to Follow Resident Dietary Restrictions Due to Incomplete Allergy Updates
Penalty
Summary
A deficiency occurred when a resident with documented allergies to pork and corn was served meals containing these items, despite their allergies being clearly indicated on their meal ticket and in their clinical records. The resident reported being served pork sausage, bacon, and corn, which did not align with their dietary restrictions. The Registered Dietitian confirmed awareness of the incident, and the Food Service Director acknowledged that the resident's allergies were listed on the meal ticket. The incident was traced back to a period when the facility was transitioning systems and had a new Food Service Director, during which some residents' dietary information, including allergies, was not properly updated. The Nursing Home Administrator confirmed that the resident was served pork products due to the failure to update dietary and allergy information during the system change. Documentation reviewed by the surveyor, including a Resident Concern Form, corroborated that the resident received bacon on their tray despite their pork allergy. The resident did not consume the pork items, but the deficiency was established based on the failure to ensure menus and meal tickets accurately reflected and were followed according to the resident's nutritional needs and documented allergies.