Failure to Accommodate Food Allergies and Preferences
Penalty
Summary
The facility failed to ensure that food allergies, intolerances, and preferences were consistently accommodated for three residents. One resident with documented allergies to cornstarch, gluten, and soybean oil was repeatedly served eggs cooked in an oil blend containing 90% soybean oil, despite clear care plan instructions and meal ticket notations to avoid soybean oil. Kitchen staff were unaware of the need to use alternative cooking oils for this resident, and the resident reported ongoing issues with being served foods containing allergens, leading her to purchase her own food to avoid adverse reactions. Another resident with a regular diet requiring pureed textures had a care plan indicating an intolerance to eggs unless cooked into food, and a preference to avoid strawberries and nuts. Despite this, the resident was served pureed scrambled eggs at breakfast, contrary to the meal ticket which specified no eggs at breakfast due to an egg yolk allergy. Staff interviews revealed a lack of awareness regarding the resident's allergies, with reliance on meal tickets for guidance, but the system failed to prevent the serving of restricted foods. A third resident, who reported allergies to fish and seafood, continued to be served these items, including a recent incident where shrimp was served despite the allergy being listed on the meal ticket. The resident's allergy was not documented in the official allergy list or care plan, and staff, including nursing assistants and LPNs, were unaware of the dietary restrictions. The facility's policies required staff to follow individualized diet orders and meal tickets, but these were not consistently referenced or updated, resulting in repeated failures to prevent exposure to known allergens.