Resident Served Allergen Despite Documented Broccoli Allergy
Penalty
Summary
A deficiency occurred when a resident with a documented allergy to broccoli was served broccoli with their dinner meal. The resident's allergy was recorded in the facility's Allergy Report, and the incident was confirmed through interviews with the resident, a CNA, and a licensed nurse. The CNA who delivered the meal admitted to missing the required check to ensure the meal matched the resident's dietary restrictions. The licensed nurse, who was responsible for verifying meal tray accuracy before delivery, stated she did not recall seeing broccoli on the tray. The Director of Nursing confirmed that three staff members—the kitchen staff, the licensed nurse, and the CNA—were responsible for ensuring dietary compliance, but the process failed at multiple points. Facility policy required that food preferences and allergies be adhered to and that food trays be checked by both the dietary department and nursing staff prior to delivery. Despite these policies, the resident received a meal containing an allergen, indicating a breakdown in the established verification process. The incident was substantiated through observation, interviews, and record review, and placed the resident at increased risk of an allergic reaction.