Failure to Provide Gluten-Free Diet as Ordered
Penalty
Summary
A resident with a documented gluten allergy and the capacity to make decisions was admitted with physician orders specifying a gluten-free diet. Despite these orders, the resident reported being repeatedly served food containing gluten, specifically cornbread, which she identified as containing gluten and therefore could not eat. During meal service, her tray was observed to include cornbread, and her meal ticket indicated her gluten allergy. The resident stated she would only eat the vegetables provided, as the cornbread would upset her stomach. Interviews with facility staff revealed that the dietary supervisor was aware of the resident's gluten allergy and that the facility used a standard cornbread mix containing wheat flour and wheat gluten. The dietary supervisor could not explain why the resident was served cornbread, and the director of nursing confirmed that dietary staff should ensure residents with gluten allergies do not receive gluten-containing foods. Facility policies reviewed indicated the importance of avoiding wheat products, including cornbread, for residents with gluten intolerance or allergies.