Failure to Prevent Shellfish Allergen Exposure in Resident Meal Service
Summary
Facility staff failed to prevent an allergic reaction for a resident with a documented severe shellfish allergy when the resident was served and consumed lobster ravioli provided by the facility. The resident’s electronic health record listed a shellfish allergy categorized as a food allergy with a severe reaction manifestation and severity, and this allergy was also reflected in the resident’s care profile. The resident had a cognitive communication deficit and was assessed as moderately impaired in cognition for making daily decisions, scoring 12 out of 15 on the BIMS. Despite these documented conditions and allergy information, the facility’s dinner menu for the skilled nursing floor included lobster ravioli, and the resident received and ate 100% of this meal. Around the time of the evening meal, the resident activated the call bell, and an LPN responded. The resident reported difficulty breathing and stated that the dinner served was shellfish, to which he was allergic. The LPN obtained vital signs, which were documented as blood pressure 124/74, heart rate 121, temperature 97.8°F, and oxygen saturation 96% on room air. Although the vital signs were noted to be within normal limits, the resident continued to report trouble breathing. The LPN attempted to contact the on-call physician service but was unable to reach a provider and then called 911 to have the resident transferred to the emergency room for further evaluation and medical management. The LPN later confirmed that the lobster ravioli had come from the facility. At the hospital, the resident was evaluated for acute onset shortness of breath and undifferentiated shock after exposure to shellfish, briefly requiring vasopressor support. The hospital documentation noted a differential diagnosis of bronchiolitis versus allergic reaction, and the resident was treated with 25 mg of Benadryl and admitted for further evaluation. Facility interviews and documentation indicated that the dietary department had a process in which resident food allergies were to be communicated via a notify form and posted allergy lists in the pantry, and that dietary aides were expected to reference these lists when plating meals. The dietician stated that the resident knew he ordered lobster ravioli and that the dietary aide should have caught the shellfish allergy, while a dietary aide described relying on the posted allergy list when plating meals. Despite these procedures and the posted allergy information, the resident with a documented severe shellfish allergy was able to order, receive, and consume lobster ravioli, resulting in an allergic reaction that required emergency treatment and hospitalization and was cited as Immediate Jeopardy with harm.
Removal Plan
- Reinforce use of the communication log posted in the Skilled Nursing pantry.
- Dietary staff verify identified residents with food allergies at each meal service using a daily updated log and dietary notification communication of resident allergies provided to dining staff.
- Educate all Skilled Nursing Facility staff (including agency staff) on the facility process: nursing enters orders into PCC; nursing completes diet notification form including food allergies and provides it to dietary; allergy is reflected on the menu ticket following manual order transcription; kitchen staff receive and verify diet order including any food allergies; kitchen staff sign and acknowledge resident food allergy via the compliance log with every meal.
- Ensure all nursing and dietary staff are educated before start of their shift; staff on PTO are educated upon return prior to next assigned shift.
- DON (or designee) audits new admission records weekly to ensure data entry and communication form process was followed for a defined period or as determined by the QAPI committee.
- Dietary Manager (or designee) monitors meal tickets for residents with food allergies weekly to ensure food allergies are included on the meal ticket for a defined period or as determined by the QAPI committee.
- Monitor process compliance and audit results in the facility QAPI program; administrator responsible for ongoing compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents did not receive meal preferences as ordered. One resident with obesity and malnutrition had an order for large portions, but meal tickets did not reflect it and staff served average portions. Another resident with COPD and obesity was told he could not have over easy eggs and was served eggs cooked hard. Interviews showed the Dietary Manager was responsible for reflecting preferences on meal tickets, while the DON and Administrator expected resident food preferences to be followed.
A dietary services lapse left multiple residents without documented assessment of food likes, dislikes, or menu choices. Several cognitively intact residents, and one moderately cognitively impaired resident, reported they were not asked about preferences, did not receive menus, and were served foods or drinks they did not want; the DSD said she was behind on nutritional risk assessments and could not produce completed menus for some residents.
A resident with dementia and a documented egg allergy was served an egg and cheese sandwich even though the chart and physician order specified no eggs. Two other residents also reported repeated meal errors, including receiving the wrong breakfast items and being served chicken instead of ordered foods such as egg salad and cream of mushroom soup. The Food Service Supervisor stated residents are supposed to receive the foods they request based on the meal ticket.
Failure to provide ordered meal alternatives and preferred fluids: A resident with class 3 obesity, L hemiplegia, and anxiety reported not liking the food and not getting enough to eat. His meal ticket ordered a heart healthy diet with a fluid restriction and no corn, but the tray observed included no alternate vegetable and did not provide the listed milk or coffee. The RD confirmed an alternate for corn should have been provided, and the NHA was informed of the missed items.
Failure to Honor Food Preferences and Ordered Diets: Two residents were served foods that did not match their tray card preferences or ordered diets. One resident received corn despite corn being listed as a dislike, and another resident with severe cognitive impairment and a vegan diet order was served whole milk, ice cream, melted butter, and meat-containing pureed food. The DS, RD, and DON all acknowledged the diet mismatches and that the vegan order had not been clarified before the meal was served.
Alternate Entree Not Equal in Nutritive Value: A facility served an egg salad sandwich and potato chips to 11 residents who requested an alternate entree, but they did not receive the other menu items on the tray. The DM and RD stated they did not compare the nutritive value of alternate entrees to the main menu item, and the DM said there was no recipe for the egg salad sandwich and he did not know its protein content or whether it was nutritionally equal to the pork roast meal.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that resident food preferences were honored for 2 residents reviewed for meal choices and dietary accommodations. Resident #2, a male with morbid obesity due to excess calories and unspecified protein-calorie malnutrition, had an order for large portions with every meal, but his lunch meal ticket on 06/29/26 did not reflect large portions and his meals observed on 06/29/26 and 06/30/26 were served as average portions. Resident #2 stated he wanted large portions with every meal, and staff interviews confirmed the meal ticket did not show the preference and that staff relied on the ticket and tray comparison. Resident #28, a male with COPD and morbid obesity due to excess calories, stated he had been told by dietary staff that he could not have over easy eggs. During observations and interviews, he reported receiving eggs cooked very hard and complained about them on multiple occasions. The Dietary Manager stated she instructed cooks to cook eggs hard to prevent salmonella poisoning and told residents they could not have runny eggs, while the Dietician stated over easy eggs could be provided if pasteurized eggs were used and that she had never been told the resident preferred otherwise. Interviews with dietary and nursing leadership showed the meal ticket system did not reliably reflect resident preferences. Staff stated the Dietary Manager was responsible for ensuring meal tickets reflected resident orders and preferences, and the DON and Administrator stated they expected food preferences to be followed. The facility policy stated residents are to receive nourishing, palatable diets that consider resident preferences and that food service staff will inspect trays to ensure the correct meal is provided.
Failure to Assess and Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that residents’ food preferences, likes, dislikes, allergies, intolerances, and choices were assessed and reflected in the meals provided for 6 of 6 residents reviewed for food preferences. Residents R1, R2, R3, R5, R6, and R7 all reported that no one had asked them about their food preferences on admission or afterward, and several stated they did not receive menu cards or other menus to choose from. R1 said the food did not taste good and that she often received plain bread with no spread; R2 said she could not eat what was served and that no one asked if she wanted something different; R3 said she disliked the fruit-flavored drink and preferred water; R5 said he tried to eat food he did not like and could not recall anyone asking about his preferences; R6 said no one had asked about her likes or dislikes; and R7, who was moderately cognitively impaired, ate about 20 percent of her lunch and said she did not like the food or drink and had not been offered menus. The Director of Dietary Services stated she was supposed to complete nutritional risk assessments for all residents upon admission, quarterly, and as needed, but she was 67 percent behind on those assessments and had completed only a few of the 24 new admissions since April 2026. She also stated that she selects residents’ likes and dislikes from the menus they complete, but she could not produce completed menus for R1, R2, or R7 because they did not ask for them. The Dietary Director’s job description stated that she was responsible for meeting with residents upon admission, conducting a nutritional assessment, ascertaining food preferences, and, after consultation with the RD, modifying the resident’s diet accordingly.
Failure to Provide Ordered Foods and Honor Allergy Restrictions
Penalty
Summary
The facility failed to accommodate residents’ food preferences and allergies for 3 of 5 residents reviewed. One resident with dementia, cerebrovascular accident, and short- and long-term memory loss was identified as having an egg allergy, and a physician order specified no eggs and no salt packets. Although nursing documented the allergy and sent a dietary communication form to the kitchen, the resident was served an egg and cheese sandwich at breakfast, and the meal ticket on the tray did not document the egg allergy. The RN stated she had notified the kitchen of the allergy, while the Food Service Supervisor stated the dietary technician was responsible for adding allergies to the meal ticket and that the cook plates the food based on what is listed. Two other residents did not receive the foods they ordered. One resident reported repeatedly receiving the wrong breakfast items, stating she asked for Cheerios, a banana, and sliced oranges but was given Cream of Wheat and diced apples instead, with no Cheerios, banana, or oranges on the tray. Another resident stated that no matter what she ordered, she kept receiving a chicken breast, and that she had ordered egg salad in a cup but was sent a chicken breast. At lunch, her tray contained chicken noodle soup instead of the cream of mushroom soup she ordered, and potato wedges were missing. The Food Service Supervisor stated residents are to receive the foods they request, that each resident has a meal ticket, and that the cook is supposed to plate food based on what the resident circled on the meal ticket.
Failure to Provide Ordered Meal Alternatives and Preferred Fluids
Penalty
Summary
The facility failed to provide food that accommodated a resident’s preferences and ordered dietary restrictions for Resident 157. The resident’s clinical record included diagnoses of class 3 obesity, left hemiplegia, and anxiety. During interview, the resident stated he did not like the taste of the food and did not get enough to eat. The resident’s meal ticket for lunch specified a heart healthy diet, a 360 ml fluid restriction, no corn, and listed vegetable soup, saltine crackers, ham steak, green beans, an alternate vegetable, ice cream, milk, and coffee. Observation of the meal tray showed the resident received vegetable soup, a saltine cracker, ham steak, green beans, and ice cream, but did not receive an alternate for corn or the milk and coffee listed on the meal ticket. The resident told the surveyor he wanted an alternate vegetable and milk to drink. The Registered Dietitian stated the resident should have received an alternate item for the corn and said she would speak with the resident regarding his fluid restriction and preferences for fluids when the menu exceeded the physician-ordered allotment for a meal. The Nursing Home Administrator was informed that the resident did not receive an alternate vegetable in place of corn and that the meal tray items met the resident’s fluid allotment for the meal without including a beverage.
Failure to Honor Food Preferences and Ordered Diets
Penalty
Summary
The facility failed to ensure resident food preferences and ordered diets were followed for two sampled residents during lunch service. One resident had corn listed as a dislike on the lunch tray card, but corn with peppers was served anyway. During the kitchen observation, the Dietary Supervisor checked tray cards and read diet orders to the cook, but did not read the dislikes on this resident’s tray card. The resident later stated the food could not be eaten, pointed to the tray card, and said corn had been placed on the tray despite being listed as a dislike. The same meal service also showed a failure to follow another resident’s ordered vegan diet. That resident had diagnoses including dysphagia, dementia, CHF, and scoliosis, and was documented as having no capacity to make medical decisions and severe cognitive impairment. During lunch observation, the resident was fed pureed food along with whole milk and ice cream. The meal ticket identified the resident as ordered for a pureed, fortified vegan diet, yet the tray contained dairy items and the pureed food was mixed with melted butter and included meat. The resident could not express food preferences and stated she did not know what foods she was being served. Interviews and record review showed the resident’s responsible party had reported a long-standing vegan diet and did not want meat or dairy products if it could be avoided. The Dietary Supervisor stated the resident should have received vegan food items and acknowledged the tray contained dairy products and meat. The Registered Dietitian stated vegan substitutes were available and that staff should have followed the vegan diet order until it was clarified with the physician. The DON stated staff must assess, document, and honor residents’ food preferences, and that if the diet order indicated vegan, ice cream, whole milk, melted butter, and meat should not have been provided.
Alternate Entree Not Equal in Nutritive Value
Penalty
Summary
The facility failed to provide alternate entrees of equal nutritive value to the entree served. During tray line service, 11 residents who requested an egg salad sandwich alternate entree received an egg salad sandwich and potato chips instead of the menu items listed for the meal, including mashed potatoes, Italian blend vegetables, and a roll with margarine. The Dietary Manager stated residents were given menus for the week and only received what they marked on the menus, and he confirmed the egg salad sandwich was used as the alternate entree only. The Dietary Manager and the Registered Dietitian both stated they did not compare the nutritive value of alternate entrees to the menu entree. The Dietary Manager said he did not know the protein content of the egg salad sandwich, did not know whether it was of equal nutritive value to the pork roast meal, and there was no egg salad sandwich recipe available. He also stated residents should still receive the rest of the meal, such as vegetables or a salad, when an alternate entree is served. The Registered Dietitian stated she relayed resident preferences but did not compare nutritive values when meal planning and did not observe alternate meals being served.
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