Failure to Follow Care Plan for Resident with Chocolate Allergy
Penalty
Summary
A deficiency occurred when a resident with a documented chocolate allergy was served a meal tray containing chocolate cake. The resident's care plan, which clearly indicated a chocolate allergy and specified that no food containing chocolate should be provided, was not followed. The allergy was documented in both the electronic health record and on the meal tray slip, which was supposed to be checked by staff responsible for meal distribution. Multiple staff members, including registered nurses, certified nursing assistants, and dietary aides, were involved in the meal tray preparation and delivery process. Despite the allergy being noted on the tray slip, a dietary aide placed the chocolate cake on the tray, and another aide, unfamiliar with the term "Black Forest Cake," did not recognize it as containing chocolate. The final verification step failed to catch the error, and the tray was delivered to the resident's room with the chocolate cake still present. The resident, who was cognitively intact, identified the error and did not consume the cake, confirming her allergy to staff. Interviews with staff revealed that while they were generally aware of the resident's allergy, lapses in communication and verification led to the failure to remove the chocolate cake from the tray. The facility's policy required staff to check tray tickets for allergies, but this protocol was not effectively followed, resulting in the deficiency.