Failure to Honor Documented Food Allergy in Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide food that accommodated a documented tomato allergy for one resident. The resident’s care plan, initiated on 8/19/25, listed food allergies to tea and tomatoes, and subsequent hospital discharge documentation and a cardiology progress note confirmed allergies including anaphylaxis to tea and mouth and throat swelling in response to tomatoes. The resident’s electronic health record and clinical dashboard also listed food allergies to tea and tomatoes, and a nutritional status problem dated 3/30/26 noted a tea allergy with an intervention to ensure allergen avoidance, but did not include the tomato allergy in the care plan. On 4/7/26 at lunchtime, the resident received a meal tray that included beef ravioli with tomato sauce, despite the documented tomato allergy. The tray ticket listed a renal diet, tea allergy, fluid restriction, and double protein portions, but did not list a tomato allergy. The actual meal observed on the tray included beef ravioli with tomato sauce, potatoes and carrots, a dinner roll, strawberry ice cream, water, and ginger ale. The resident informed the Medical Records Director, who was delivering the tray, that he was allergic to tomatoes and requested an alternate meal, stating he could not eat processed deli meat and chose an egg salad sandwich instead. Interviews revealed that the resident reported being served tomatoes and tomato sauce previously and had told staff delivering trays that he could not eat tomatoes. The Medical Records Manager, who also worked as a nurse aide when delivering trays, stated she checked tray tickets for allergies and diets and was unaware of the tomato allergy because it was not on the tray ticket. A nurse aide familiar with the resident also stated she was not aware of a tomato allergy and relied on tray tickets for allergy information. The Dietary Manager reported she was unaware of the tomato allergy, explained that nursing entered allergies into the clinical record and that she was responsible for ensuring allergies appeared in the meal tray ticket system, and noted that tea was listed as an allergy in her system but tomatoes were not. The DON stated she expected food allergies to be communicated from nursing to dietary and honored, and that allergies were supposed to transfer from the clinical dashboard to the Dietary Manager’s system and be included on the diet order slip provided to dietary.
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