Failure to Accommodate Resident's Nut Allergy
Penalty
Summary
Silver Lake Healthcare Center was found to be non-compliant with federal and state regulations regarding the accommodation of resident allergies. The deficiency was identified during an abbreviated survey conducted in response to complaints. The survey revealed that the facility failed to provide food that accommodated a resident's known nut allergy. Specifically, the resident, who is allergic to nuts, was served a cookie containing peanuts, which was not in accordance with her dietary restrictions as noted on her meal ticket. The incident occurred when the resident consumed part of the cookie and began experiencing an allergic reaction, characterized by an itchy throat and difficulty swallowing. The nursing staff responded by administering Benadryl and an EpiPen, as the resident had a history of serious allergic reactions. The resident was assessed by an on-site nurse practitioner, and her condition stabilized following the administration of the medication. Interviews with staff confirmed the occurrence of the allergic reaction and acknowledged that the cookie appeared to be a sugar cookie but contained nuts, which had not happened before.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. 1. Corrective Action for Resident #1: Resident #1 was discharged from the facility on 01/14/2025. 2. Identification of Other Residents Potentially Affected: All residents currently in the facility have the potential to be affected by the alleged deficient practice. An audit of all residents was conducted on 01/21/2025 by Dietitian to ensure that allergies are accurately documented in both the Electronic Medication Administration Record (EMAR) and the Meal Tracker system. Any inaccurate or missing allergies will be corrected. 3. Systemic Changes to Prevent Recurrence: The Executive Director/designee will provide in-service training to Dietary, Activity Staff and Clinical staff on ensuring meal tray accuracy by 01/24/2025. The training will emphasize the importance of adhering to dietary restrictions and ensuring that meal trays are accurate based on the resident's documented needs and the information on meal tickets. The Executive Director/designee will implement an audit process to verify the accuracy of meal trays. 4. Monitoring and Quality Assurance: - Audits will be completed by Executive director /designee to review meal trays for 3 random residents to ensure the meal contents match the items listed on the meal tickets. This will be completed 5x's weekly for 4 weeks, then weekly for 3 months, and subsequently on a random basis. - Findings from the meal tray accuracy audits will be reported during the monthly Quality Assurance and Performance Improvement (QAPI) meetings for a period of 3 months. Afterward, monitoring and reporting will continue on a random basis.