Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
A resident with documented allergies to shellfish, squash, all melons, bananas, and cucumbers repeatedly received meals containing these allergens despite informing facility staff of her allergies. The resident reported being served a salad with cucumber and a tray with melons on multiple occasions, and provided photographic evidence of the meals. Interviews with staff, including a CNA and the Dietary Manager, confirmed that the resident had been served foods she was allergic to. The Dietary Manager was unaware of all the resident's allergies, and there was confusion regarding whether cucumber was an allergy or a dislike, as reflected by handwritten changes on the resident's meal ticket. The Registered Dietitian also did not confirm the cucumber allergy directly with the resident, relying instead on information from the resident's daughter. The resident's care plan and medical records clearly listed her allergies, and the facility's policy required identification and accommodation of food allergies. Despite this, the resident continued to receive meals containing allergens, and staff interviews revealed a lack of consistent understanding and communication regarding her dietary restrictions. The facility had previously documented the need to double-check the resident's trays and ensure unwanted items were not served, but these measures were not effectively implemented, resulting in repeated exposure to allergens.