Failure to Adhere to Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to adhere to documented food preferences and allergy-related restrictions for one resident, resulting in the resident being served food items that were either disliked or posed an allergy risk. The resident, who was cognitively intact and had a documented chocolate allergy and a dislike for rice, was observed receiving a broccoli chicken rice casserole instead of the listed spaghetti with meat sauce, despite rice being noted as a dislike on her food slip. Additionally, the resident was served a piece of chocolate cake, even though her tray slip clearly indicated a chocolate allergy. Multiple staff interviews revealed that dietary and nursing staff were aware of the resident's chocolate allergy and food preferences, and that tray slips included this information. However, there was a breakdown in the process of verifying and assembling meal trays. Some staff members did not recognize that "Black Forest Cake" contained chocolate, and others admitted to possibly placing incorrect items on trays. The final verification process failed to prevent the chocolate cake from being served to the resident. The facility did not provide a policy related to adhering to food preferences and allergy-related restrictions. Staff, including dietary aides, CNAs, and the Dietary Kitchen Manager, acknowledged the errors and confirmed that the resident should not have received rice or chocolate. The administrator confirmed that staff are expected to follow tray slips carefully, especially regarding allergies and preferences, but this expectation was not met in this instance.