Failure to Communicate and Accommodate Resident Food Allergy
Penalty
Summary
A deficiency occurred when a resident with a documented allergy to eggs was not properly accommodated during meal service. The resident's admission and allergy records clearly indicated an egg allergy, but this information was not reflected on the resident's diet order or meal tray ticket. As a result, the resident was served potato salad containing mayonnaise, an egg-based product, during lunch. After consuming a portion of the meal, the resident experienced symptoms consistent with an allergic reaction, including throat itchiness, shortness of breath, and throat constriction, prompting her to seek assistance from nursing staff. Interviews with facility staff revealed that the dietary kitchen assistant, who was in charge at the time, did not have access to or the ability to modify resident meal preferences or allergy information. The kitchen staff relied solely on the tray card for guidance, which did not list the egg allergy. The certified nursing assistant who served the meal did not verify the ingredients with the kitchen staff before serving the tray. Additionally, the following morning, the resident's breakfast tray again lacked an indication of the egg allergy on the preference card, despite the allergy being documented in the resident's records. The facility's policies required that resident allergies be reflected on tray cards and that food service staff be aware of such allergies. However, the failure to update and communicate the resident's egg allergy on the tray ticket and to verify meal ingredients led to the resident being served food containing eggs on multiple occasions. This lapse in communication and adherence to policy resulted in the resident experiencing an allergic reaction and requiring medical intervention.