Failure to Consistently Accommodate and Document Resident Food Allergies
Penalty
Summary
The facility failed to consistently accommodate and document food allergies for a resident with multiple allergies, resulting in the resident being served food items to which they were allergic. Specifically, the resident, who had diagnoses including diabetes, hypertension, and dementia with moderate cognitive impairment, was observed receiving a breakfast tray containing a hard-boiled egg, despite an egg allergy being listed on their diet ticket. The resident confirmed an allergy to eggs, reporting gastrointestinal symptoms upon ingestion, and stated they would not eat the eggs provided. Additionally, the resident's diet ticket and electronic health record contained inconsistent documentation of allergies, with some allergies such as peaches not being listed on the diet ticket, even though peaches were served multiple times in the facility's menu cycle. Interviews with staff, including CNAs, the DON, the Food Service Director, and the Dietitian, revealed that there were discrepancies between the allergies listed on the diet ticket, the electronic health record, and physician orders. Staff acknowledged that allergies should be checked by both kitchen and nursing staff before food is served, but the process was not consistently followed. The Food Service Director was unaware of the resident's peach allergy due to its omission from the diet ticket, and the Dietitian admitted to not cross-referencing diet ticket allergies with those in the electronic health record during assessments. These lapses led to the resident being at risk of receiving foods they were allergic to.