Failure to Prevent Allergen Exposure Due to Inadequate Tray Card Identification and Verification
Penalty
Summary
The facility failed to follow established procedures for accommodating a resident's documented food allergies, resulting in the resident being served fish despite a known seafood allergy. The resident, who had diagnoses including dysphagia and a gastrostomy, was on a regular, no added salt, pureed diet with specific restrictions against white bread, milk, citrus, cheese, caffeine, and seafood. The resident's tray card, which should have clearly indicated these allergies, displayed the seafood allergy in small letters and not in pen, making it less noticeable to dietary staff. As a result, the kitchen assistant did not see the allergy and served the resident pureed fish. The resident consumed the fish, believing it to be chicken, and subsequently experienced an allergic reaction, including itching and numbness, requiring administration of Benadryl. Interviews with staff revealed lapses in the tray verification process. The dietary supervisor acknowledged the error and noted the allergy was not prominently marked on the tray card. The kitchen assistant confirmed the allergy was not easily visible, and the licensed vocational nurse admitted to not checking the tray due to other duties. The director of nursing emphasized the importance of double-checking trays to prevent such incidents. Facility policies required tray cards to list allergies and for staff to check trays for accuracy, but these procedures were not adequately followed, leading to the resident receiving an allergen-containing meal.