Failure to Verify Meal Tray Contents Against Updated Allergy Information
Penalty
Summary
The facility failed to ensure that kitchen staff or licensed nurses checked the contents of a meal tray against the meal tray ticket for a resident during breakfast service. Specifically, a resident with a history of paraplegia and moderate cognitive impairment was served apple juice, despite the meal tray ticket indicating an allergy to apple juice. The resident confirmed they were not allergic to apple juice, and previous assessments and care plan updates had removed apple juice from the resident's allergy list. However, the meal tray ticket still listed the allergy due to a system glitch during a transition to a new dietary meal ticket system. Dietary staff did not review the tray on the day in question, and the discrepancy between the resident's actual allergy status and the information on the meal tray ticket was not identified by either dietary or nursing staff. The facility's policy required both dietary and nursing staff to check trays for correct diets and allergies before serving, but this process was not followed, resulting in the resident being served an item incorrectly listed as an allergen on their tray ticket.