Failure to Identify and Document Resident Food Allergy Prior to Meal Service
Penalty
Summary
The facility failed to obtain and document a resident's dietary allergies prior to serving food, resulting in a resident being served shrimp despite having a shellfish allergy. The resident, who was cognitively intact, reported that shortly after admission, he was served shrimp and had to inform the aide of his allergy, prompting the removal of the meal tray. The resident had a history of an allergic reaction to shrimp, characterized by throat tightness and difficulty breathing. The resident's representative later contacted the facility to ensure staff were aware of the shellfish allergy, after which the allergy was added to the medical record. Interviews with facility staff revealed inconsistencies in the process for identifying and documenting allergies upon admission. The admitting nurse did not record any allergies, as none were listed on the hospital discharge paperwork. The Dietary Manager did not recall meeting with the resident's family, and the process for gathering allergy information varied among staff. The Director of Nursing and Regional Registered Dietician both indicated that allergies should be identified and documented within 24-48 hours of admission, but this did not occur prior to the resident being served a meal containing shellfish.