Failure to Accommodate Documented Seafood Allergy in Resident Meal Service
Penalty
Summary
Resident R13, who had documented diagnoses including anoxic brain damage, cerebral infarction, and chronic obstructive pulmonary disease, was admitted to the facility with a known and recorded allergy to crab and seafood. Despite this, the resident was served shrimp alfredo for dinner, as confirmed by a review of the nutrition assessment, physician orders, and dietary manager interview. Following the meal, the resident vomited, with whole dinner contents present, and later reported the incident to staff. The resident's granddaughter also filed a grievance, expressing concern that seafood was served despite the known allergy. The deficiency was identified through observation, record review, and staff interviews, confirming that the facility failed to provide food in a form that met the resident's individual dietary needs.