Failure to Prevent Allergen Exposure
Penalty
Summary
The facility failed to prevent exposure to a food allergen for a resident with a known allergy, resulting in an allergic reaction. The facility's policies, including the Nutrition Services Communication Form and Food Allergen Awareness, were not effectively implemented. These policies were designed to ensure communication between nursing and dietary staff and to prevent allergic reactions by identifying food allergens. However, on 11/11/2024, a resident with a documented fish allergy was mistakenly served a breaded fish patty instead of the specified breaded pork patty. This error occurred despite the meal tray ticket indicating the correct item, and the mistake was only realized after the resident began to develop a rash following consumption of the meal. The incident was confirmed by the Nursing Home Administrator during an interview on 12/23/2024, acknowledging that the facility did not adhere to the physician's orders to avoid serving the resident a food allergen. The deficiency was identified through a review of facility policies, clinical records, and staff interviews, highlighting a lapse in the facility's management and communication processes. The failure to provide the correct meal as per the resident's dietary restrictions led to an adverse health event, violating several Pennsylvania Code regulations related to resident care and rights.
Plan Of Correction
R1 was immediately sent to the hospital for assessment after the incident. All other food allergies in the facility were reviewed, and residents were interviewed to verify no allergic foods have been provided to them. An updated allergy list will be available to dietary staff and nursing staff to review. The Nutrition Services Supervisor or designee will highlight food allergies on meal tickets for every meal. The Nutrition Services Supervisor or designee will educate dietary and nursing staff on how to read meal tickets and how to cross-reference the tray with the ticket before serving by 1/23/25. The Nutrition Services Supervisor or designee will audit all trays with food allergies for accurate meal items during one meal per day daily for one week, weekly for one month, and monthly thereafter. Findings will be discussed at the Quality Assurance Performance Improvement meeting.