Failure to Accommodate Documented Food Allergies
Penalty
Summary
A deficiency occurred when a resident with documented allergies, including peas, was served fried rice containing peas. The resident reported that she is allergic to peas due to an enzyme deficiency that causes her stomach upset, and stated that she is served foods she is allergic to at least once a week. Observation confirmed the presence of peas on her lunch tray, and the meal ticket clearly listed peas as an allergy and as a strong dislike. The resident's medical record and care plan both documented her allergies, including peas, and her history of multiple medical conditions such as IBS, GERD, obesity, and eating disorders. Despite these documented allergies and clear instructions on the meal ticket, the resident continued to receive foods containing her allergens. A previous grievance report indicated that the resident had complained about being served her allergens, and staff had been educated on the issue. However, the deficiency persisted, as evidenced by the recent incident where the resident was again served peas. The Dietary Manager acknowledged that allergies are highlighted on meal tickets and that multiple staff are supposed to check trays, but was unable to explain how the error occurred.