Failure to Honor Food Allergies, Intolerances, and Preferences
Penalty
Summary
The facility failed to ensure that food allergies, intolerances, and preferences were honored for four residents out of six sampled for dietary concerns. One resident, who had documented allergies to fish, seafood, and tomatoes, was served a fish sandwich and stewed tomatoes despite these allergies being listed in both hospital and provider records available in the facility. The resident experienced an allergic reaction after consuming the fish sandwich, requiring administration of an epinephrine auto-injector. Staff interviews revealed a lack of awareness and communication regarding the resident's allergies, and the Director of Nursing acknowledged that the allergy information was present in the medical record but not acted upon. Another resident with chewing and swallowing difficulties, as well as a broken wrist, was repeatedly served food that was not cut into bite-sized pieces as required by their care plan and tray card instructions. The resident reported difficulty eating and swallowing the food provided and stated that requests for dietary consultation were not addressed. The Registered Dietician confirmed the need for a mechanically altered diet and that food should be cut into small pieces, but the resident continued to receive whole pieces of meat. Two additional residents reported that their food preferences and dislikes, such as avoiding gravy, were not honored, with meal tickets indicating dislikes that were not followed by dietary staff. Both residents stated that they had informed staff of their preferences, but the issues persisted. Food committee meeting minutes and staff interviews confirmed ongoing problems with meal ticket accuracy and repeated errors in honoring resident preferences and allergies, despite in-services and audits. Facility policies required identification and accommodation of allergies and preferences, but these were not consistently implemented.