Failure to Document and Manage Severe Nut Allergy Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to document the severity of a resident's nut allergy, failed to develop and implement a care plan addressing the allergy, and did not ensure that all recipes used in the kitchen were reviewed for food allergens before serving food to residents. The resident, who had a documented history of severe nut allergy, was admitted with multiple diagnoses including asthma and dysphasia, and was cognitively intact. Despite the resident and her family providing information about her nut allergy and its severity, this information was not fully documented in the electronic health record or communicated to the interdisciplinary team. The facility's admission and care planning processes did not include specific details about the resident's allergic reactions, nor were food restrictions related to her allergies included in her orders or care plan. The dietician noted the allergy in personal notes but did not share this information in the resident's chart or with the interdisciplinary team. The kitchen staff were unaware of the resident's nut allergy and continued to use a recipe containing nuts, as the recipe was not included in the template reviewed for allergens. As a result, the resident was served a dessert containing nuts, which led to an anaphylactic reaction. Following the consumption of the dessert, the resident experienced symptoms including periorbital swelling, itching, and oxygen desaturation, requiring administration of Benadryl and oxygen, and subsequent transfer to the emergency room for treatment of anaphylactic shock. Interviews with facility staff revealed that allergies were not routinely included in baseline care plans, and staff relied on discharge summaries rather than direct interviews with residents to determine allergy severity and reactions. The lack of communication and documentation directly contributed to the resident being exposed to a known allergen, resulting in harm.