Failure to Care Plan and Honor Resident’s Egg Allergy and Double-Portion Preference
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and individualized interventions to address a resident’s documented egg allergy and preference for double portions at each meal. The resident was admitted with multiple diagnoses including spinal stenosis, type 2 diabetes with hyperglycemia, discitis, end stage renal disease, and weakness. The medical record included a physician’s order for an LCS/NAS diet with regular texture and thin liquids, and a history and physical that listed allergies to aspirin, codeine, and eggs. A comprehensive MDS showed the resident had intact cognition (BIMS score of 14) and was on a therapeutic diet. However, the comprehensive care plan revised on 01/13/26 did not include the resident’s egg allergy or preference for double portions. During an interview, the cognitively intact resident reported repeated problems with meals over the past weekend, stating that staff kept sending eggs despite the egg allergy and were not providing the requested double portions. The resident stated they had taken photos as evidence and had called the kitchen and spoken with the Director of Kitchen Services several times. The resident’s meal tickets, as shown in photos dated 02/07/26, clearly listed the diet order, egg allergy, dislike of eggs, and a note for double portions/2x meat or protein, along with specific standing orders for breakfast items. Despite this, a photographed breakfast tray showed only a single slice of toast (cut in half) and one slice of breakfast ham, and a photographed lunch tray showed a chef’s salad containing chopped boiled egg. In interviews, the DON explained that care plans are implemented by various clinical staff based on identified focus areas, and a unit manager RN acknowledged that food allergies and preferences should be included in the comprehensive care plan.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.