Failure to Accommodate Resident Food Allergies in Meal Service
Penalty
Summary
A resident with documented food allergies to mayonnaise and eggs was repeatedly served meals containing these allergens. The resident's medical record was updated to reflect these allergies on 4/30/25, and the allergy was included in the May 2025 allergy report. Despite this, the resident was served potato salad and a tuna fish sandwich, both of which typically contain mayonnaise, as well as a ham salad sandwich made with mayonnaise. The resident reported being served foods containing allergens on multiple occasions and attempted to address the issue with nurse aides and nurses, but was told it was a kitchen issue. Facility staff interviews revealed that the process for communicating food allergies involved nursing staff alerting the kitchen, with dietary aides responsible for reading dietary tickets to avoid serving allergens. However, the allergy was not initially listed on the resident's record, and even after the record was updated, the resident continued to receive inappropriate meals. Observations confirmed the resident was served a sandwich containing mayonnaise, which was only removed after intervention by the Food Service Director. The Director of Nursing confirmed that it was the charge nurse's responsibility to resolve food issues by contacting the kitchen, and acknowledged the resident should not have been served foods they were allergic to.