Failure to Follow Care Plan for Food Allergy
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dementia, feeding difficulties, and a documented allergy to tomatoes, was served food containing tomato despite clear care plan instructions and physician orders indicating the allergy. The resident's care plan specifically stated that tomato should not be served at meals, and the dietary order reinforced this restriction. However, the resident was given ketchup on a hotdog, which was delivered from the kitchen on the resident's tray. The incident was documented in nursing progress notes and led to a grievance filed by the resident's family. A CNA reported offering ketchup and mustard to the resident, who accepted, and only realized the tomato allergy after the resident had consumed several bites. The facility's policy required implementation of a comprehensive, person-centered care plan, but in this instance, the care plan related to the resident's food allergy was not followed.