Failure to Train Dietary Staff on Gluten-Free Diets Leads to Allergen Exposure
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in preparing and serving gluten-free diets, resulting in a resident with a documented gluten allergy being served cream of wheat. The resident, who had diagnoses including cachexia, intestinal malabsorption, and non-celiac gluten sensitivity, was admitted with clear physician orders and allergy documentation indicating the need for a gluten-free and lactose-free diet. Despite these orders, the resident was served cream of wheat, a product containing gluten, for breakfast. The resident identified the error and reported previous instances of being served inappropriate foods, such as oatmeal and regular bread, despite informing staff of his allergies. Interviews with dietary staff revealed confusion and lack of knowledge regarding gluten-free diets. One dietary aide stated she was told by a previous supervisor that cream of wheat was acceptable for gluten-free diets and reported that it was served daily to residents on such diets. The dietary supervisor confirmed that no training on gluten-free diets had been provided to kitchen staff since assuming her position. Additionally, the registered dietitian acknowledged that the facility's menu software did not properly flag the resident's gluten allergy, and there was a lack of clarity regarding the availability of gluten-free alternatives such as cream of rice, which was in stock but not used. A review of facility policies, procedures, and competency checklists showed that while staff were trained on general food allergies and preferences, there was no specific training or competency verification for gluten-free diets. The facility's policies required identification and accommodation of food allergies, but these were not effectively implemented. The deficiency was further evidenced by the lack of accurate tray identification and the absence of gluten-free diet training in staff in-service records.