Failure to Honor Resident's Vegetarian Diet Preference
Penalty
Summary
A deficiency occurred when a resident with a documented vegetarian diet preference, including no eggs and no meat, was not provided with meals that honored these preferences. The resident's admission diet order specified a regular vegetarian diet with no eggs or meat, but the care plan did not address these dietary restrictions. The Minimum Data Set (MDS) listed a diabetic diet, and the resident's lunch ticket indicated a regular diet, resulting in the resident being served meals containing meat, such as a pork sandwich. The resident reported consistently receiving meat with meals and only being able to eat the salad, leading to hunger and repeated reminders to staff about her dietary needs. Interviews with facility staff revealed confusion regarding the resident's diet orders, with multiple conflicting diet orders present in the system, including regular, consistent carbohydrate (CCHO), and vegetarian diets. The Dietary Director acknowledged the lunch ticket was incorrect and confirmed the resident should have been on a CCHO and vegetarian diet. The DON was unaware the resident had received the incorrect diet and stated the expectation was for all residents to receive the correct diet. The failure to provide the appropriate diet was confirmed through record review, observation, and interviews.