Resident Served Allergen Despite Documented Food Allergy
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including allergies to peach and lactose, was served a food item containing peach despite clear documentation of these allergies on the resident's admission records, face sheet, and meal card. The resident's family member identified the error when peach was found on the lunch tray and reported it to staff. The family member stated that the resident experiences severe skin irritation and throat closure when exposed to peach. Interviews with dietary staff and the Dietary Manager revealed that the kitchen staff are required to refer to the meal card, which documents food allergies, when setting up meal trays. On the day of the incident, dietary aides admitted to missing the allergy information due to a busy day, resulting in the resident being served peach. The Director of Nursing confirmed that staff are expected to follow the meal card instructions to prevent such occurrences. Facility policy requires that food allergies be communicated to dining services and identified on individual tray assembly tickets.