Failure to Accurately Document and Communicate Resident Food Allergy
Penalty
Summary
The facility failed to ensure that a resident's food allergy was accurately identified, documented, and communicated to all relevant staff. Upon admission, the resident's records, including the Allergy Report, Diet Type Report, and Care Plan, did not indicate any food allergies, despite the resident reporting an allergy to all peppers except black pepper. The dietary supervisor interviewed the resident and was informed of the allergy but only entered 'bell pepper' in the menu system, as that was the only type of pepper typically served, and did not update the allergy section of the medical record. The dietary supervisor also stated she did not have the capacity to enter allergies into the electronic medical record (EMR), and assumed nursing staff would handle this task. A licensed vocational nurse (LVN) was informed by the resident about the pepper allergy after the resident was served food containing bell peppers. The LVN did not take the resident's report seriously, did not document the allergy in the medical record, and did not communicate the information to other healthcare team members. The LVN relied solely on the history and physical records, which did not list any allergies, and failed to notify the physician or update the Medication Administration Record (MAR). The LVN also did not inform the kitchen staff or endorse the allergy to other nursing staff, and admitted to lacking specific training on food allergies. The facility's policy required comprehensive assessment and documentation of resident allergies, as well as communication among the interdisciplinary team and updates to care plans. However, the process was not followed in this case, resulting in the resident being served a food item containing an allergen. The deficiency was further compounded by a lack of clear responsibility for entering allergy information into the EMR and insufficient staff training regarding food allergy management.