Failure to Honor Resident Food Preferences and Allergies
Penalty
Summary
The facility failed to consistently honor residents' food and drink preferences, allergies, and intolerances as documented on their meal tickets and care plans. Multiple residents were observed being served food items they had specifically indicated as dislikes, such as sausage, eggs, black pepper, carrots, zucchini, and lima beans, despite these preferences being clearly listed. Residents expressed frustration, sadness, and anger over receiving unwanted food and drink items, and some reported that this was a common occurrence. In several cases, residents left the unwanted food uneaten, and one resident noted that she did not receive the correct number of coffee creamers as requested. In addition to disregarding preferences, the facility also failed to prevent exposure to known food allergens. One resident with documented allergies to cucumbers and pickles was served potato salad containing pickles, which resulted in him experiencing mouth itching and requiring antihistamine and anti-nausea medication. The resident expressed ongoing fear and vigilance regarding his meals due to this incident. Review of his records showed that his allergies were documented in multiple places, including his meal ticket and medical record, but this information was not effectively communicated to or recognized by all staff involved in meal delivery. Interviews with dietary staff and CNAs revealed a lack of awareness and adherence to residents' documented food preferences and allergies. The dietary manager confirmed that food items were available to meet residents' preferences but were not provided as required. Staff also failed to cross-reference ingredient lists with residents' allergies, leading to the serving of allergenic foods. The facility's own policy required that food preferences be identified and honored on tray tickets, but this was not consistently implemented.