Failure to Accommodate Resident's Food Intolerances
Penalty
Summary
The facility failed to provide food that accommodates a resident's intolerances and preferences, as evidenced by the case of a resident who was served wheat and milk despite having documented intolerances to these items. The resident, who was observed eating breakfast in her room, reported that she had been served wheat and milk on multiple occasions, despite her requests for alternatives such as almond milk. The resident's care plan and physician orders indicated that she should not be served milk or wheat, and that almond milk should be used instead. However, the facility did not have almond milk available at the time, and the resident's meal ticket incorrectly included items she was intolerant to. Interviews with the facility's dietary staff, including the cook, dietary aides, Certified Dietary Manager (CDM), and Diet Technician (DT), revealed a breakdown in communication and responsibility. The dietary aides admitted to errors in reviewing meal tickets, and the CDM acknowledged that the resident was served items she was intolerant to, despite having documented these preferences. The DT confirmed her role in updating meal tickets and expressed confusion over the oversight. The facility's policy on food preferences and intolerances was not effectively implemented, leading to the resident being served inappropriate food items.
Plan Of Correction
Resident #163 was discharged from the facility. Residents with food intolerances and preferences have the potential to be affected by not honoring intolerances and preferences. The Registered Dietician/diet tech will review residents with food intolerances to ensure the residents' tray ticket and care plan are accurate. The diet tech/food service director will interview residents to ensure their food preferences are accurate and are correct on residents' tray tickets. The facility added a food tray checker at the end of the tray line to verify the tray is accurate, honoring the resident's intolerances and food preferences. The Registered Dietitian/Designee will in-service the food and nutrition staff on the process for ensuring residents with intolerances are not served those food items and that food preferences are honored. This training will include the process for checking the tray prior to serving. The Director of Nursing/Designee will in-service licensed nurses, certified nursing assistants, and activity staff on the need to ensure that the items on the tray match the tray ticket and that food items that the residents are to avoid or have intolerances to are not served, and that food preferences are provided. The Registered Dietitian/Designee will complete 5 random weekly meal observations to ensure that residents are not served items they are to avoid or have intolerances to and are provided their food preferences. The results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.