Failure to Assess and Document Resident Food Allergy
Penalty
Summary
Licensed Vocational Nurse 8 (LVN 8) failed to demonstrate the necessary knowledge and skills to properly assess and document a resident's reported food allergy. The resident, who had a medical history including multiple sclerosis, hypertension, and diabetes, reported being allergic to all types of pepper except black pepper. However, the resident's admission record, allergy report, and diet type report did not indicate any food allergies, and the care plan only noted a no added salt diet without mention of a pepper allergy. Despite the resident informing both the Dietary Supervisor and LVN 8 about the pepper allergy, the information was not accurately entered into the medical record or communicated to the interdisciplinary team. The Dietary Supervisor only entered 'bell pepper' in the menu system, as that was the only type of pepper served, and did not update the allergy section of the electronic medical record. LVN 8 did not document the allergy, notify the physician, update the Medication Administration Record, or communicate the allergy to other staff, as he believed the resident was joking and relied solely on the history and physical records, which did not list any allergies. Interviews with facility leadership revealed that there was no specific training provided to staff regarding food allergies, only training on data entry into the medical record system. The facility's policies required comprehensive assessment and documentation of allergies, as well as communication among the interdisciplinary team, but these procedures were not followed in this case. As a result, the resident was served food containing bell peppers, contrary to his reported allergy.