Failure to Prevent Shellfish Allergy Exposure
Summary
The facility failed to ensure that a resident with a known allergy to shellfish was not served shellfish, resulting in an allergic reaction. The resident, identified as R209, was admitted to the facility with a documented allergy to shellfish, as noted in both the admission note and care plan dated 10/9/24. Despite this, on 10/13/24, R209 was served a meal containing shrimp, leading to an allergic reaction that required emergency treatment. The incident was identified as an immediate jeopardy situation due to the severity of the allergic reaction. Interviews and document reviews revealed that the communication process for food allergies was flawed. The health unit coordinator (HUC) was responsible for entering allergy information into the electronic medical record (EMR) and completing a dietary sheet for the kitchen staff. However, R209's shellfish allergy was not included on his meal ticket prior to the incident. The culinary director (CD) was the only staff member with access to the dietary system to verify and add food allergies, which contributed to the oversight. Staff interviews indicated that food allergies should be listed on meal tickets and in the EMR, but this was not consistently checked by all staff members. The root cause of the deficiency was identified as a dietary sheet lacking a designated area for allergies, which led to the failure to communicate R209's shellfish allergy to the kitchen staff. This oversight resulted in the resident being served shrimp, despite having a history of severe allergic reactions to shellfish. The facility's policies and procedures for documenting and communicating food allergies were insufficient, leading to the incident where R209 experienced an allergic reaction and required emergency medical attention.
Removal Plan
- All residents were audited for current food allergies.
- The new admission form was modified to add an area specifically to address resident food allergies.
- Dietary policy related to meal tickets was reviewed.
- Resident allergy documentation was reviewed.
- Staff were educated on the meal ticket handling policy and what to do with new admissions form.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a documented No Added Salt (NAS) diet and clear instructions for no sauce, gravy, or chicken skin was repeatedly served meals that did not follow these specifications. During one observed meal, the resident received chicken with skin and gravy despite the diet card prohibiting these items, and the resident reported that the previous evening’s dinner plate also contained a large amount of gravy. The resident stated they did not report the issue to staff because they did not want to complain and feared their meal would be delayed, demonstrating that the facility did not consistently honor the resident’s documented food preferences and restrictions.
The facility failed to provide a variety of appealing meal substitutions in line with resident preferences and its own written menu standards. Although the alternate menu listed deli sandwiches, grilled cheese, chef salads, and bread, residents and staff consistently reported that only grilled cheese, and occasionally ham sandwiches without cheese, were offered when residents refused the main meal. Resident council leaders and multiple residents stated they had repeatedly complained about the lack of variety and the removal of prior options such as hamburgers and pizza, without any resolution. CNAs, an LPN, and an RN confirmed frequent resident complaints and the limited substitution choices, while dietary staff and the Food Service Manager acknowledged that budget-driven changes had reduced the alternate menu and that key salad ingredients like tomatoes and cucumbers were not routinely stocked, resulting in monotonous and restricted substitution offerings.
A resident with diabetes, heart failure, and HTN, who was cognitively intact and on a consistent carb, regular texture diet, repeatedly received oatmeal on meal trays despite stating multiple times that he did not like it. Review of the care plan and nutrition assessment showed no documented food preferences, and the daily menu for the resident lacked any notation of likes or dislikes, even though the facility’s policy and the DM’s process required recording such information on nutritional assessments and menus.
Failure to Honor Documented Food Dislike: A resident with dementia and malnutrition had a documented dislike for breakfast sausage on the meal ticket, yet sausage was served on breakfast trays during two observations. The resident stated she did not eat breakfast sausage, and dietary staff and the ADM confirmed it should not have been served.
Two cognitively intact residents with documented food dislikes were repeatedly served items listed as dislikes and did not consistently receive alternate menu selections they ordered. One resident received beets despite this item being listed as a dislike and reported frequently having to request a peanut butter and jelly sandwich instead, while another resident with rice listed as a dislike reported receiving incorrect meals and that the menu was wrong on most days of a week. Surveyors also observed that the posted menu listed spiced pears, but residents were served mangoes with whipped topping, and a dietary aide stated that staff often prepared whatever food was on hand rather than what was on the menu. The Administrator acknowledged emerging dietary issues and confirmed that residents should not receive foods on their dislike/allergy lists and that served food should match the menu or be communicated if changed.
Failure to honor documented food allergies, intolerances, and preferences: Two residents were served foods listed as allergies or dislikes, including raw tomatoes, milk, tomatoes, and cucumbers. One resident’s chart also failed to include a documented raw tomato allergy, and lactose-free milk was not available on the unit drink cart despite being in the kitchen. The NHA and DON confirmed the transcription and meal service failures.
Failure to Honor Resident’s Documented Food Preferences and Restrictions
Penalty
Summary
The facility failed to honor a resident’s documented food preferences and diet specifications when serving meals. During a dining observation, the resident reported she was not supposed to have gravy or chicken skin, yet her lunch tray contained chicken with the skin on and gravy covering the chicken. Review of the resident’s meal card on the tray showed an order for a No Added Salt (NAS) diet with explicit instructions for no sauce, gravy, or chicken skin. The resident further reported that her dinner plate the previous evening had a lot of gravy, and she did not report the concern to staff because she did not want to complain and was worried her meal would arrive later if she did. Review of the facility’s daily dinner menu for that evening showed that crispy pork cutlet with gravy was served, indicating that the resident’s stated and documented preferences and restrictions were not followed.
Failure to Provide Variety and Choice in Meal Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with a variety of appealing meal substitutions consistent with resident preferences and the facility’s own policy. The facility census showed 58 residents, with 57 on oral diets, and the Alternate Menu listed deli sandwiches, grilled cheese, chef’s choice salad, and bread as substitution options. However, interviews and observations revealed that in practice residents were typically only offered grilled cheese sandwiches, with occasional ham sandwiches that were served without cheese. The Food Service Manager reported that hamburgers, hot dogs, and pizza had been removed from the substitution menu after a budget review, and that the alternate list was reduced to deli sandwiches and grilled cheese. Multiple residents, including resident council leaders, stated they did not like the food served and that the only consistent substitution offered was grilled cheese, despite the facility’s written list of other options. Residents reported that they had previously been offered a wider variety of substitutions such as pizza and hamburgers, but those options were no longer available. Some residents stated they had repeatedly voiced concerns at meals and during resident council meetings about the lack of variety and appealing choices, but no changes were made, leading at least one resident to stop speaking up because complaints did not result in any resolution. Staff interviews corroborated the residents’ complaints. Several CNAs and nursing staff stated that residents frequently complained about the food, the lack of variety, and the limited substitutions, confirming that grilled cheese was essentially the only substitute offered. The Food Service Manager acknowledged that the chef salad on the substitution list was limited to lettuce, American cheese, and deli meat, and that items like tomato and cucumber were only included if they happened to be on the main menu and in stock, as they were not ordered specifically for substitution salads. During a lunch observation, kitchen staff confirmed that there were no cucumbers, tomatoes, or onions available, and grilled cheese sandwiches were seen prepared in a steamtable pan on the serving line, further demonstrating the restricted and repetitive nature of the substitution offerings.
Failure to Document and Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that a resident’s food preferences were documented and honored, resulting in the resident repeatedly receiving an undesired food item. During an interview, Resident B, who was cognitively intact per a 5-day MDS assessment, reported that he did not like oatmeal and had continued to receive it on his meal tray despite telling staff several times not to send it. Review of his medical record showed he was admitted with diagnoses including diabetes, heart failure, and hypertension, and had a physician’s order for a consistent carbohydrate, regular texture diet. However, his care plan contained no specific food preferences, and his nutrition assessment only stated that food preferences were on the tray card, with no additional information recorded. The DON stated that food preferences were recorded on nutritional assessments, while the DM explained that residents were given daily menus and asked to indicate what they wanted, and that she would include likes and dislikes if residents informed her. Neither the DON nor the DM reported being told of any food preferences by this resident. The DM provided a copy of the daily menu for the resident, which lacked any notation of likes or dislikes at the bottom where such information was supposed to be recorded. The facility’s policy, “Clinical Nutrition documentation,” stated that residents have the right to make their own food choices related to individual differences and cultural and ethnic preferences, but the documentation and meal service for this resident did not reflect his stated dislike of oatmeal.
Failure to Honor Documented Food Dislike
Penalty
Summary
The facility failed to honor and accommodate a resident’s food preference by serving breakfast sausage despite the resident’s documented dislike for it. Resident #68 was admitted with diagnoses including unspecified dementia and unspecified protein-calorie malnutrition, and her most recent MDS showed a BIMS score of 12, indicating moderately impaired cognition. Her meal ticket listed a special note that she disliked breakfast sausage. During observations on two separate mornings, Resident #68 was seen with a breakfast sausage patty cut up on her breakfast plate, and she stated both times that she did not eat breakfast sausage. During the second observation, the dietary staff member confirmed that breakfast sausage was listed as a dislike on the meal ticket and should not have been served. The administrator also confirmed that because breakfast sausage was listed as a dislike, it should not have been served to the resident.
Failure to Honor Food Preferences and Follow Posted Menus
Penalty
Summary
The deficiency involves the facility’s failure to honor resident food preferences, provide listed menu items, and offer appropriate alternatives. One cognitively intact resident, identified as Resident 2, had a documented dislike of beets on their meal slip but was observed receiving a lunch tray with a large serving of cut-up red beets. Resident 2 reported that they often received foods they did not like and frequently had to request a peanut butter and jelly sandwich instead. Resident 2 stated they had repeatedly spoken with the Administrator (Staff A) about ongoing problems with food service. Another cognitively intact resident, identified as Resident 3, was observed with a lunch tray containing mashed potatoes and reported that they were surprised because, when rice was on the menu, that was usually what they received. Resident 3 pointed to their meal slip, which listed rice under dislikes, and reported that they often ordered from the bistro menu but still received the main meal instead. Resident 3 stated the menu had been incorrect for four of seven days in the previous week. Additionally, during an observation of the posted daily menu, residents were supposed to receive spiced pears, but trays contained mangoes with whipped topping instead. A dietary aide (Staff F) confirmed that mangoes were served and stated that day-shift staff frequently prepared whatever food was on hand rather than what was on the menu. The Administrator (Staff A) acknowledged there were emerging issues in dietary services and affirmed that residents should not receive items on their dislike/allergy lists, should be able to receive alternate menu items they order, and that served food should match the menu or be communicated to residents if changed.
Failure to Honor Documented Food Allergies, Intolerances, and Preferences
Penalty
Summary
The facility failed to provide food and beverages in accordance with residents’ documented allergies, intolerances, and stated food preferences for two residents. Resident 188’s lunch meal ticket identified a lactose allergy and dislikes for pineapple and raw tomatoes, but during lunch the resident was served a side salad containing raw tomatoes and a cup of white whole milk. At the time of the meal, the resident stated she was allergic to raw tomatoes, pineapple, and milk. Staff confirmed the resident was served raw tomatoes despite the meal ticket identifying tomatoes as a dislike, and the unit drink cart did not have lactose-free milk available even though an unopened half-gallon was present in the kitchen walk-in refrigerator. Clinical record review showed a CRNP progress note documented dietary allergies to chocolate, raw tomatoes, pineapple, and lactose intolerance, but the allergy list in the medical record included pineapple and lactose and did not include raw tomatoes. Resident 167’s lunch meal ticket documented dislikes of tomatoes and cucumbers, yet the resident was served a side salad containing both items. The resident stated he frequently receives foods identified on his dislike list. The NHA and DON confirmed the facility failed to accurately transcribe dietary allergies in the medical record and failed to ensure residents received meals consistent with their documented allergies, intolerances, and preferences.
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