Failure to Follow Allergy-Specific Diet Order and Provide Adequate Meal Replacement
Penalty
Summary
Facility staff failed to ensure that a resident’s menu and meal service met her nutritional needs and documented food allergy, resulting in a shellfish-containing entrée being served to a resident with a known shellfish allergy. The resident was admitted with multiple diagnoses including status post reverse arthroplasty of the left shoulder, asthma, hypertension, and gastroesophageal reflux disease, and had a clearly documented shellfish allergy in the Physician’s Order Reconciliation and History and Physical. An admission MDS showed the resident was cognitively intact, and the care plan identified risk for altered nutritional status with interventions to provide the prescribed diet, note the shellfish allergy, provide ordered nourishment/supplements, and honor food preferences. On the date of the incident, the facility’s dinner menu included penne pasta with spinach and shrimp. The resident’s meal ticket, as later observed by the surveyor, listed multiple shellfish-related allergies and had a red circular sticker indicating an allergy. Despite this, the pantry worker plated the shrimp entrée for the resident. The pantry worker reported that she based plating on the diet type listed on the ticket (e.g., regular or mechanical) and stated that on the new ticket format the allergy information was printed much smaller, and that she had not received sufficient training, which she believed contributed to her error. The Chef Manager stated that pantry workers are supposed to read the ticket and only plate food specific to the resident, and that nurses are supposed to read the ticket and ensure the food is correct before giving it to the resident. A CNA delivered the tray containing shrimp to the resident’s room. The CNA stated that her usual practice is to place the tray on the table and then remove the dome cover to check the meal against the ticket, but on this occasion she did not do so because the resident’s daughter assisted and immediately took the tray. The daughter opened the cover, saw the shrimp, and stated that the resident was allergic, at which point the CNA apologized and returned the tray to the kitchen. The complaint submitted to the State Agency reported that the replacement food initially offered consisted of a peanut butter and jelly sandwich, a ham sandwich, and two bags of potato chips, which was described as not nutritionally appropriate for an elderly patient, and that subsequent attempts to remedy the situation included three small pieces of chicken in a plastic container and later a container of cold spinach, leading the complainant to reorder a meal on the resident’s behalf.
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