Resident with Documented Food Allergy Served Allergenic Food Item
Penalty
Summary
A deficiency occurred when a resident with documented allergies to avocado, banana, and strawberries was served a breakfast tray containing half a banana. The resident's admission record and order summary report clearly indicated these allergies, and the resident was also noted to have dysphagia, asthma, and a history of repeated falls. The resident's cognitive status was moderately impaired, and they required significant assistance with daily activities. During the tray line observation, the dietary aide admitted to missing the allergy sign on the tray due to nervousness and acknowledged the importance of checking for allergy tags, which are written in red, to prevent such errors. The dietary supervisor confirmed that both the dietary aide and supervisor are responsible for checking meal trays to ensure residents with food allergies do not receive restricted items. Facility policy requires identification of food allergies upon admission and mandates that meals for residents with severe allergies be specially prepared to avoid exposure and cross-contamination. Despite these procedures, the resident was still served a food item to which they were allergic, as observed and confirmed during the survey.
Plan Of Correction
F-tag 800 I: Corrective Action for residents found to have been affected: • On 05/17/2025, a banana was removed from Resident 194's meal tray by the dietary supervisor prior to meal tray delivery. II: Facility's Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • Residents with food allergies were audited by the dietary supervisor on 5/17/2025. No other residents identified with the same deficient practice. • An immediate in-service education was provided by the dietary supervisor on 5/18/2025 to dietary staff to ensure that residents' identified allergies are not provided in the resident's meal tray. III: Measures and systemic changes put in place to ensure deficient practices do not recur: • The Registered Dietitian will conduct a tray line observation on a weekly basis for 1 month, then monthly for 3 months to ensure residents will not receive identified food allergy items on the food tray. IV. Facility's plan to monitor corrective actions are achieve & sustain compliance: • Integrate the POC to QA Process. • The result of tray line observation conducted by the RD will be reported by the Dietary Supervisor during the monthly QAA meeting for 3 months to ensure compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/25