Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to provide meals that accommodated a resident's documented food allergies and religious preferences on multiple occasions. The resident, who had a documented allergy to raw tomatoes and a religious preference to avoid pork, was served meals containing these items on several dates. Despite the resident's care plan and food preference assessments clearly indicating these restrictions, meal tickets and photographic evidence showed that the resident received pork and raw tomatoes in her meals. The resident reported experiencing allergic reactions, including swelling of the mouth and hives, after consuming tomato seeds, and required administration of Benadryl as documented in the medication administration record. Interviews with staff revealed that new and agency dietary aides were not consistently following meal tickets or were unfamiliar with resident preferences. The dietary manager and other staff acknowledged awareness of the resident's allergies and preferences, but lapses occurred due to staff turnover, lack of familiarity, and failure to check meal tickets before serving trays. The dietary manager had recently begun reassessing all residents' food preferences and had provided in-service training and counseling to dietary staff regarding the importance of adhering to meal tickets and resident preferences. The facility's own policy required that each resident be provided with meals that meet their nutritional and special dietary needs, including allergies and preferences, and that food trays be inspected to ensure accuracy. Despite this, the resident continued to receive meals containing allergens and foods contrary to her religious beliefs, as confirmed by staff interviews, resident statements, and photographic documentation.