Failure to Prevent Allergic Reaction Due to Inadequate Allergy Management
Summary
The facility failed to ensure that a resident with a known severe allergy to ginger received a meal that accommodated this allergy. The resident, who was cognitively intact and required setup assistance for eating, was served a meal containing honey ginger chicken, which led to an anaphylactic reaction. Despite having an order for epinephrine to be used in such cases, the resident was not administered the medication because it was on hold due to insurance issues, and the staff did not have it available in the emergency medication kit. The resident's care plan and dietary communication indicated allergies to ginger and bee pollen, but this information was not accurately reflected in the nutrition program used by the dietary staff. The meal tray ticket for the resident did not list any food allergies, and the dietary staff failed to verify the meal contents against the resident's allergy information. This oversight resulted in the resident consuming the allergen and experiencing a severe allergic reaction, necessitating emergency medical intervention. Interviews with facility staff revealed a breakdown in communication and procedure adherence. Dietary staff were expected to enter and verify allergy information in the nutrition program, which should have prevented the ordering of allergenic foods. However, the system did not flag the ginger allergy, and the meal tray ticket did not display this critical information. Additionally, the facility's emergency preparedness was inadequate, as the necessary medication for anaphylaxis was not readily available, highlighting a significant lapse in ensuring resident safety.
Removal Plan
- Conduct a whole house audit by nutrition services to verify all residents' allergies listed in the medical record are accurately listed in the nutrition system and that those allergies accurately print on the residents' meal tray ticket.
- Implement a process to ensure residents receive appropriate food items and not receive identified food allergens.
- Ensure meal service observation identifies staff confirm the meal served matches the meal tray ticket and any food allergies listed on the meal ticket are not served.
- Ensure R23's orders and stocked medication include epinephrine.
- Review E-kit contents to ensure inclusion of epinephrine.
- Start nutrition staff education on allergy information communication and entry into the nutrition system, meal service, meal ticket and allergy review, and tray assembly.
- Start nursing staff education on verification that the meal delivered matches the tray ticket and does not contain any food allergens.
- Include nursing education on E-kit contents, use of epinephrine via a vial, standing house orders, signs and symptoms of anaphylactic reaction, procedure for allergic and anaphylactic reactions, and incident reporting.
- Educate all staff prior to their next shift.
- Continue compliance monitored via meal service audits.
- Review audit results by the quality committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident did not receive timely or complete meals when dietary meal tickets failed to print and staff were unaware the meals were missing. On one morning, the resident waited in a wheelchair in her room well past normal breakfast time before receiving a tray with only cream of wheat and toast, without requested items such as eggs, orange juice, sugar, butter, or jelly. The previous evening’s supper had also been delayed for the same reason. Facility policy required that residents be provided palatable, attractive food at a safe, appetizing temperature and that food be prepared and served in compliance with safe food handling practices.
A resident with documented allergies to tea and tomatoes, including prior mouth and throat swelling from tomatoes, was served a meal containing tomato sauce because the tomato allergy was not included on the care plan interventions or the dietary tray ticket, even though it appeared in the clinical record. At lunch, the resident received beef ravioli with tomato sauce on a renal diet tray that only listed a tea allergy, and reported having been served tomatoes and tomato sauce on previous occasions despite informing staff. The Medical Records Manager, a NA, and the Dietary Manager all stated they were unaware of the tomato allergy and relied on tray tickets or electronic transfers of allergy data, which only reflected the tea allergy, while the DON stated she expected nursing-entered allergies to be communicated to dietary and honored.
A resident with Alzheimer’s disease and other comorbidities, who was cognitively impaired and dependent on staff for care, was not provided a meal consistent with documented food preferences and restrictions. During a breakfast service, the resident received pureed sausage, scrambled eggs, pureed toast, and cranberry juice, despite a meal ticket specifying yogurt, half a banana, tea, and no juice or soda. A CNA confirmed the resident did not receive the ordered items and was served juice contrary to the documented restriction, in violation of facility policy requiring that individualized food preferences and restrictions be reflected in the tray ticket system.
The facility failed to provide alternate meal choices of similar nutritional value and did not consistently honor resident food and beverage preferences during a period when the main kitchen was closed and meals were prepared from the dining room using limited equipment. Only a single entrée was offered at each meal, with peanut butter and jelly or deli sandwiches as the only substitutes, and several residents reported they could not order and were simply served whatever was prepared, including food they disliked or items that did not match their stated preferences. Residents also did not consistently receive requested beverages such as chocolate milk, 2% milk, cranberry juice, fruit punch, or ice with meals, and one resident reported being served burnt pizza with no alternative. The Dietary Manager confirmed there was no second meal option of similar nutritive value during the shutdown and that new dietary aides had not been fully trained on tray line duties.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
Failure to Provide Timely and Complete Meals Due to Missing Dietary Tickets
Penalty
Summary
The facility failed to meet residents' nutritional needs in accordance with established national guidelines when a resident did not receive timely and complete meals due to errors in the dietary ticketing and delivery process. On the morning of 04/06/26, the resident was observed sitting in a wheelchair in her room at 9:00 AM with her bedside table in front of her, waiting for her breakfast tray. At 9:30 AM, a nurse aide informed her that the kitchen had not yet delivered the food cart to the hall and that her tray would be delivered once it arrived. By 10:00 AM, the resident was still waiting for breakfast. When questioned at 10:05 AM, Administrative Nurses D and E acknowledged that the resident should have received breakfast before 10:00 AM. At 10:10 AM, the resident finally received a tray containing cream of wheat and one piece of toast, without sugar, butter, or jelly. The resident reported that she had requested eggs and orange juice but was told by staff that those items were unavailable and that what she received was all that was available. Administrative Nurse E verified that the kitchen had not printed a breakfast ticket for the resident, which resulted in her not receiving her meal on time. Dietary Staff BB later confirmed that the resident had not received her breakfast tray because the meal ticket did not print and also verified that the resident’s supper meal the previous evening had been delayed for the same reason. The facility’s Food Preparation and Service policy, dated 10/2025, states that residents are to be provided with food that is palatable, attractive, and at a safe and appetizing temperature, and that food service employees should prepare and serve food in a manner that complies with safe food handling practices.
Failure to Honor Documented Food Allergy in Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide food that accommodated a documented tomato allergy for one resident. The resident’s care plan, initiated on 8/19/25, listed food allergies to tea and tomatoes, and subsequent hospital discharge documentation and a cardiology progress note confirmed allergies including anaphylaxis to tea and mouth and throat swelling in response to tomatoes. The resident’s electronic health record and clinical dashboard also listed food allergies to tea and tomatoes, and a nutritional status problem dated 3/30/26 noted a tea allergy with an intervention to ensure allergen avoidance, but did not include the tomato allergy in the care plan. On 4/7/26 at lunchtime, the resident received a meal tray that included beef ravioli with tomato sauce, despite the documented tomato allergy. The tray ticket listed a renal diet, tea allergy, fluid restriction, and double protein portions, but did not list a tomato allergy. The actual meal observed on the tray included beef ravioli with tomato sauce, potatoes and carrots, a dinner roll, strawberry ice cream, water, and ginger ale. The resident informed the Medical Records Director, who was delivering the tray, that he was allergic to tomatoes and requested an alternate meal, stating he could not eat processed deli meat and chose an egg salad sandwich instead. Interviews revealed that the resident reported being served tomatoes and tomato sauce previously and had told staff delivering trays that he could not eat tomatoes. The Medical Records Manager, who also worked as a nurse aide when delivering trays, stated she checked tray tickets for allergies and diets and was unaware of the tomato allergy because it was not on the tray ticket. A nurse aide familiar with the resident also stated she was not aware of a tomato allergy and relied on tray tickets for allergy information. The Dietary Manager reported she was unaware of the tomato allergy, explained that nursing entered allergies into the clinical record and that she was responsible for ensuring allergies appeared in the meal tray ticket system, and noted that tea was listed as an allergy in her system but tomatoes were not. The DON stated she expected food allergies to be communicated from nursing to dietary and honored, and that allergies were supposed to transfer from the clinical dashboard to the Dietary Manager’s system and be included on the diet order slip provided to dietary.
Failure to Follow Documented Food Preferences and Restrictions
Penalty
Summary
The facility failed to provide meals according to a resident’s documented food preferences and restrictions. A resident with Alzheimer’s disease, congestive heart failure, anxiety, and seizures, admitted in mid-September 2024, had a comprehensive MDS indicating a cognitive deficit and dependence on staff for all care. The resident’s care plan showed a need for supervision and occasional feeding assistance. On the observed breakfast service, the resident was served pureed sausage, scrambled eggs, pureed toast, and cranberry juice, with appropriate adaptive equipment. However, review of the resident’s meal ticket for that breakfast showed the resident was supposed to receive yogurt, half a banana, and tea daily, with explicit instructions for no juice or soda. Despite these documented preferences and restrictions, the resident was served juice instead of tea and did not receive the ordered yogurt and banana. A CNA confirmed that the resident was not supplied the ordered food and acknowledged that residents’ preferences changed often. Facility policy on accommodation of food preferences required that resident food preferences be listed in the tray ticket system and that alternate menu items be available to meet individualized needs and requests, but this was not followed in this instance.
Failure to Provide Alternate Meal Choices and Honor Resident Food Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide appealing meal options of similar nutritive value and to honor residents’ food preferences during a prolonged kitchen shutdown and subsequent transition period. For 19 days while major plumbing repairs were performed in the kitchen and dry storage, the facility prepared meals out of the dining room using limited equipment such as roasters, crockpots, a microwave, a griddle, and a waffle maker. During this time, only one meal choice was offered at each meal, and the only substitutes available were peanut butter and jelly sandwiches or deli sandwiches. The Dietary Manager confirmed that there was no second meal option of similar nutritional value available during the kitchen shutdown. Multiple residents reported not being able to order or receive their preferred items. One resident stated there were no second options or substitute items and that he was simply given food he did not like, including peas, carrots, and rice. Another resident’s meal ticket indicated a preference for chocolate milk, which was not provided on the tray. A different resident reported she does not order and is just served whatever is given; her stated preferences for 2% milk, cranberry juice, and fruit punch resulted in her receiving only fruit punch. Another resident reported being served burnt pizza with no other option when the kitchen was down and stated that even when she tells staff what she wants, she usually does not receive it; her ticket also indicated she should receive ice with every meal and fruit punch at lunch, neither of which were delivered. The Dietary Manager further acknowledged that new dietary aides were still in training and had not been given sufficient time to learn their tray line duties during and immediately after the kitchen relocation.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
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