Failure to Honor Dietary Allergies, Intolerances, and Preferences
Penalty
Summary
The facility failed to ensure that food allergies, intolerances, and dietary preferences were honored for four out of five residents reviewed for nutritional services. One resident, who was a vegetarian with a moderate cognitive impairment, repeatedly received meals containing meat despite clear documentation of her dietary restrictions and multiple grievances filed on her behalf. The resident and her family communicated these concerns to staff, and the care plan specifically noted her vegetarian status and food preferences. Despite these measures, the resident continued to receive incorrect meals, leading to emotional distress and ultimately her discharge against medical advice. The facility was unable to provide a vegetarian menu to surveyors upon request, and meal tickets did not consistently reflect the resident's preferences or the interventions taken by dietary staff. Another resident with a documented shellfish allergy was served shrimp, contrary to the dietary order and meal ticket instructions. Staff interviews revealed that the process for assembling meal trays involved multiple checks, but the system failed, resulting in the resident being exposed to an allergen. The resident had a history of moderate allergic reactions to shellfish, and the care plan included clear instructions to avoid exposure. Staff confirmed that the resident had previously experienced a reaction to shrimp, and the allergy was documented in the medical record. Despite this, the resident was served shrimp, and the incident was only discovered after the meal was delivered. Additional deficiencies included a resident who was supposed to receive large portions but consistently received standard portions, and another resident with lactose intolerance and diabetes who was repeatedly served dairy products and sweets. In both cases, the residents' dietary needs were clearly documented in their records and on meal tickets, but the kitchen staff failed to provide the correct meals. These failures were confirmed through direct observation, interviews with residents and staff, and review of dietary documentation.