Failure to Include Shellfish Allergy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing a resident's shellfish allergy. Upon review, the resident's care plan did not include any focus area, goal, or intervention related to the shellfish allergy, despite the resident being cognitively intact and having a documented history of a severe allergic reaction to shrimp. The resident reported being served shrimp shortly after admission, at which time he informed the aide of his allergy and had the meal tray removed. The resident's representative also contacted the facility to ensure staff were aware of the allergy after learning about the incident. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for documenting food allergies in the care plan. The Regional Registered Dietician was unsure if food allergies should be included in the care plan, while the MDS Nurse and Dietary Manager each believed the other was responsible for this task. The DON confirmed that there was no designated person assigned to ensure food allergies were added to care plans. This lack of clear assignment and communication resulted in the resident's shellfish allergy not being addressed in the care plan.