Failure to Manage Documented Fish Allergy Resulting in Fatal Reaction
Summary
The deficiency involves the facility’s failure to ensure that a resident’s documented food allergy was thoroughly assessed and consistently integrated into care planning and dietary practices, resulting in the resident receiving fish despite a known fish allergy. The resident was admitted with lung and breast cancer and had a BIMS score of 15, indicating no cognitive impairment. The admission Nursing Data Base Assessment did not document any food allergies. On 1/28/26, the RD completed a Nutrition Assessment that documented a fish allergy but did not specify the type of fish, the resident’s reaction, or the severity. The admission MDS and Nutritional Status CAA completed on 1/30/26 did not document any food allergy, and the resident’s care plan also lacked any entry regarding a fish allergy, including type of fish or severity, although the Physician Plan of Care did document fish as an allergy. The RD reported that the resident verbally disclosed a fish allergy, that she assumed this applied to all types of fish, and that she did not ask for specific details about the reaction or its severity. The RD also stated she does not do care planning and believed all food allergies would be written into the care plan, and that she reviews hospital paperwork for allergies; in this case, no food allergies were documented in the hospital records. The Director of Food Services stated that the menu for the day in question listed a combo cheese and spinach quesadilla, creamed corn, and Mediterranean baked fish, and that a combo plate would include a little of everything, including fish. The DFS stated that the diet technician or RD meets with new admissions for likes, dislikes, and allergies, which are entered into the electronic medical record and communicated to the menu system, and that the resident’s meal ticket did identify the fish allergy, but the cook did not follow it. On the day of the incident, the resident was served fish for lunch and later requested that a CNA heat up leftover food. The CNA observed the food and told the resident it was fish, while the resident believed it was chicken. The resident stated it had better not be fish because they were allergic, prompting the CNA to check the meal ticket, see the fish allergy, and notify the floor nurse and the nursing supervisor. A progress note later documented that around 1500, the supervisor arrived to find the floor nurse taking vitals; the resident was in an armchair, alert, verbal, with vital signs including BP 163/66, pulse 40, respirations 22, temperature 97.2, and oxygen saturation 94% on 4L O2 via nasal cannula, with no shortness of breath, cough, difficulty breathing, or cyanosis, and denying pain. The note describes a subsequent drop in pulse, notification of the MD, instruction to call 911, the resident becoming anxious, trembling, losing consciousness, then briefly responsive, removing and replacing O2, followed by dilated pupils, shaking, arm flailing, loss of consciousness, and absence of a palpable pulse before EMT arrival. The facility’s investigation concluded that the resident received fish and had an allergic reaction, and the resident passed away related to this event, leading to a finding of Immediate Jeopardy beginning on 3/15/26.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to honor a resident’s requested diet texture. A resident with intact cognition and diagnoses including RA, PTSD, and recurrent MDD repeatedly asked for a regular diet, but staff continued serving a mechanically altered/blended diet. She reported that staff ignored her requests, while CNA and nursing interviews confirmed she was not eating the facility trays and was instead getting other foods. The DON and DOR acknowledged concern about possible choking, but also stated the resident had the right to choose her diet plan and that her request for a diet upgrade was denied without further discussion.
Failure to provide resident-selected menu items: Residents reported that meals were not being served as shown on the menu, including a missed special holiday meal and menu days that were not identified. The menu included Resident's Choice and regional breakfast selections, but the CDM stated the planned Port of Call meal could not be obtained from the distributor, and the Corporate Dietician confirmed the facility did not provide residents with their selected menu items and preferences.
Meal tray tickets did not consistently match resident preferences or allergy information. One resident with dementia was served apple juice instead of the orange juice listed on the tray ticket, and staff said tray tickets should be followed to meet resident needs. Another resident with a documented lactose allergy had a tray ticket that did not reflect the allergy, and staff interviews showed the allergy was not consistently communicated to dietary even though the resident reported still receiving milk on meal trays.
Failure to honor documented food preferences: A resident with type 2 DM and moderate cognitive impairment received a lunch tray with ham despite a tray ticket listing pork as a dislike. The resident stated dietary staff had not been following the tray ticket and confirmed the pork preference had been discussed more than once.
Failure to Honor Food Preferences and Offer Meal Alternatives: A resident with intact cognition, DM, and mild protein-calorie malnutrition reported skipping breakfast because she disliked the meals being served and said staff did not ask about her food preferences or offer substitutes with adequate nutritive value. A CNA observed an untouched breakfast tray at the bedside, took it back to the kitchen after the resident declined it, and did not offer an alternative; the RDM and RD stated meal alternatives are important to meet nutrition needs and food preferences.
A resident did not receive a fresh fruit cup that was listed in the Notes section of the lunch meal ticket as a food preference. During the meal observation, the tray did not include the fruit cup, and the resident stated she wanted it. An LVN verified the meal ticket, and the DSS stated items in the Notes section were resident preferences that should be included with the meal.
Failure to Honor Resident’s Requested Diet Texture
Penalty
Summary
The facility failed to provide food that accommodated a resident’s preference for a regular diet, despite the resident’s repeated requests for non-mechanically altered food. Resident #53 was admitted with diagnoses including rheumatoid arthritis, PTSD, and recurrent major depressive disorder. Her quarterly MDS showed a BIMS score of 15 out of 15, indicating no cognitive impairment, and her care plan reflected that she was on a regular diet/mechanical soft with thin liquids and that staff were to honor her meal choices. The care conference record also noted that she complained of diet texture and that follow-up was planned. During observation and interview, Resident #53 stated she had lived at the facility for years, had no teeth, and could not stand the food because staff insisted on serving her a mechanical blended diet. She said she ordered her own food and had CNAs prepare instant oatmeal, pasta, and other items for her, and that she had asked repeatedly for regular food but staff ignored her. She stated she had been eating a regular diet for years without problems. Observation later showed a CNA delivering a lunch tray that included a blended beef tator tot casserole, mixed vegetables, and a smoothie; the resident accepted only the smoothie and returned the rest of the tray untouched. Staff interviews confirmed that Resident #53 was not eating the facility-provided meals and was instead obtaining other foods. A CNA stated the resident never accepted her meal trays and sometimes accepted drinks, while an LVN said the resident had always bought her own food and did not eat the facility food. The ADON and DOR stated the resident had previously worked with ST because she would eat while lying down and scooping food from the plate, and they expressed concern about possible choking, though they were not aware of any choking incidents. The MDS Coordinator stated the resident requested a diet upgrade to regular food at the care conference, reported having had a swallow study and being able to eat regular food, and that the request was denied without further discussion; she also stated the resident was not informed of the outcome.
Failure to Provide Resident-Selected Menu Items
Penalty
Summary
The facility failed to provide resident-selected menu items for 5 of 12 residents identified in the report: R707, R708, R709, R710, and R711. Review of facility policy showed that meal identification and food preference cards were to be used to properly identify each individual's food and beverage needs, and the Resident Rights and Facility Responsibilities policy stated the facility would comply with resident rights. During the Resident Group Meeting, residents stated that meals were not being provided as shown on the menu, that some menu days were not identified, and that a special meal for Memorial Day was not provided. Review of the Spring Summer Menus showed a four-week rotation cycle with two Thursday lunch meals listed as Resident's Choice and two Thursday breakfast meals listed as Regional breakfast favorite. The Regional Dietician stated that certain menu choices were determined at the corporate level for Port of Call days and sent to each facility by email with the selected meal, ingredients, portion sizes, and consistency instructions, and that lunch resident choices were supposedly decided during resident council meetings. The Certified Dietary Manager stated he could not obtain the food from the distributor for the Hawaii Port of Call and therefore could not provide the planned Thursday meal. The Corporate Dietician later confirmed that the facility failed to provide residents with their selected menu items and preferences as indicated on the menus.
Meal Tray Tickets Did Not Match Resident Preferences or Allergy Information
Penalty
Summary
The facility failed to ensure that residents received foods that matched their documented preferences and allergy information. One resident with dementia and severe cognitive impairment had a breakfast tray ticket that listed orange juice, but apple juice was served instead. During observation and interview, the resident stated she liked orange juice and was okay with the apple juice that day, and she also said that sometimes she did not receive everything on her tray ticket. Staff acknowledged that the tray ticket did not match the meal served and stated that tray tickets should be followed to meet resident needs and preferences. A second resident with diagnoses including burns and a documented lactose allergy had a lunch tray ticket that did not reflect the lactose allergy listed in the medical record and care plan. The resident stated he was lactose intolerant and reported that he still received milk on meal trays. He said he knew not to consume lactose products, but it would be helpful if the kitchen did not provide them. Staff interviews showed that the Dietary Manager, CNA, DON, and ADM were not consistently aware of the lactose allergy being communicated to dietary, and the DON stated the allergy should have been on the meal tray ticket. Record review showed the first resident’s care plan included providing and serving the diet as ordered, and the second resident’s care plan identified lactose allergy. The facility’s policies stated that food preferences, dislikes, and allergies should be obtained and that tray cards should be updated to reflect appropriate information. The Dietary Manager and other staff stated that meal tray tickets should be followed to ensure the right diet, texture, and resident, but the tray ticket for one resident did not match the ordered beverage and the tray ticket for the other resident did not reflect the documented lactose allergy.
Failure to Honor Documented Food Preferences
Penalty
Summary
The facility failed to honor a resident’s food preferences by serving a lunch tray that included ham despite the resident’s documented dislike of pork. Resident #12 was admitted with type 2 diabetes mellitus and had a BIMS score of 9 out of 15, indicating moderate cognitive impairment. During observation, the resident stated that dining staff had not been following the tray ticket listing food dislikes and showed the tray ticket from breakfast, which included pork as a dislike. When the resident’s lunch tray was delivered, ham was observed on the plate, and the resident stopped the CNA delivering the tray to request an alternative main entree. The resident confirmed that pork, including the ham served, was not liked and stated this had been discussed with dietary staff on more than one occasion.
Failure to Honor Food Preferences and Offer Meal Alternatives
Penalty
Summary
The facility failed to honor food preferences and failed to offer meal substitutes of the same nutritive value for one sampled resident. Resident 122 was admitted and later readmitted to the facility and had diagnoses including osteoarthritis of the right knee, DM, and mild protein-calorie malnutrition. The MDS dated 4/2/2026 indicated the resident’s cognitive skills for daily decision making were intact, that the resident required setup and clean-up assistance with meals, and that the resident required moderate assistance with ADLs. The H&P dated 5/7/2026 indicated the resident had the capacity to understand and make decisions. During an interview on 5/18/2026, Resident 122 stated she did not like the breakfast meals being served and reported skipping breakfast because she was unhappy with the food provided. She stated that no staff asked for her food preferences and no meal substitutes with adequate nutritive value were offered. During a concurrent observation and interview on 5/20/2026, CNA 4 observed an untouched and covered breakfast tray with scrambled eggs and oatmeal at the bedside table and stated the resident declined the tray, it was taken back to the kitchen, and no meal alternative or food preference was offered. The Regional Dietary Manager stated not providing meal alternatives could lead to poor intake, and the RD stated it was important to offer other food choices when a resident refused a meal to help meet nutrition needs and food preferences. The facility’s Dignity policy stated the facility culture supports dignity and respect for residents by honoring resident food choices and preferences.
Missed Resident Food Preference on Meal Tray
Penalty
Summary
The facility failed to ensure that one of 27 sampled residents, Resident 31, received food that accommodated the resident’s preferences. During the lunch meal observation on 5/18/26, Resident 31 was observed eating in her room with a tray that included a baked hamburger with brown sauce, capri blend vegetables, fried diced potatoes, a wheat roll, and a fruit crisp dessert. Review of the resident’s lunch meal ticket showed a note to add a fresh fruit cup, but the fruit cup was not present on the tray. When asked, Resident 31 stated she would like to have her fruit cup for her lunch meal. Resident 31 had been admitted to the facility and later readmitted. During the concurrent observation and interview, LVN 7 reviewed the meal ticket and verified that the fresh fruit cup should have been included. The DSS stated that items listed in the Notes section of the meal ticket were resident preferences for the meal and that if listed, the resident should have that item in addition to the menu items. The Administrator, ADON, and DON were informed of and acknowledged the findings.
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