Failure to Provide Palatable, Nutritious, and Proper-Temperature Meal to Resident With Shellfish Allergy
Penalty
Summary
Facility staff failed to provide a cognitively intact resident with a nourishing, palatable, well-balanced, attractive meal at a safe and appetizing temperature, as required by facility policy. The resident had multiple diagnoses including status post reverse arthroplasty of the left shoulder, asthma, hypertension, and gastroesophageal reflux disease, and a documented shellfish allergy. The resident’s care plan identified risk for altered nutritional status and directed staff to provide the prescribed diet, note the shellfish allergy, provide ordered nourishment/supplements, and honor food preferences. On a dinner menu that included penne with spinach and shrimp, the resident, who could not receive shellfish, required an alternative meal. According to the complaint intake, the replacement food offered for dinner 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. Subsequent attempts to remedy the situation included three small pieces of chicken served in a plastic container, followed later by a container of cold spinach at approximately 7:03 PM. The Dietary Director acknowledged that an “Always Available Menu” existed with hot and cold items that could be ordered without a cut-off time and that such items should be served on a plate and logged as a special request. The Dietary Director also acknowledged awareness that the alternative food item served to the resident was cold, but was not aware of how the resident would have received it in a to-go container.
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