Failure to Document and Accommodate Food Allergy and Preferences
Penalty
Summary
The facility failed to properly document and accommodate a resident's egg allergy and food preferences, resulting in deficiencies in care. The resident, who had a documented allergy to eggs in multiple records including the admission record, history and physical, dietary interview, and care plan, did not have this allergy indicated on her meal tray ticket. Observations confirmed that the tray ticket only listed eggs as a dislike, not as an allergy, and staff interviews revealed that the allergy should have been clearly marked to prevent exposure. The dietary supervisor, registered nurse, registered dietician, and director of nursing all acknowledged that the allergy was not properly documented on the tray ticket, which could lead to the resident being served eggs. Additionally, the facility failed to provide an appropriate food substitution for the resident during breakfast when eggs were not served. On observation, the resident's breakfast tray did not contain eggs, but also lacked a protein substitute. The dietary supervisor confirmed that a protein should have been provided in place of the egg and subsequently added yogurt to the tray after the deficiency was noted. The resident expressed a preference for yogurt, and the dietary supervisor emphasized the importance of protein in the diet. The facility's own policy and procedure on food allergies and intolerances required that all resident-reported food allergies be documented in assessment notes, care plans, and diet slips, and that appropriate substitutions be offered for foods that cannot be eaten. Despite these policies, the resident's egg allergy was not properly communicated on the tray ticket, and a suitable substitution was not provided at breakfast, resulting in a failure to meet the resident's nutritional needs and accommodate her allergy.