Failure to Prevent Serving Allergen-Containing Food to Resident with Documented Anaphylactic Allergies
Penalty
Summary
The facility failed to ensure that a resident with documented anaphylactic allergies was not served food containing allergens. Specifically, a resident with known allergies to mayonnaise, salad dressing, mustard, nuts, and teriyaki sauce, and a history of prior anaphylactic reactions, was served a salad with mayonnaise on her lunch tray. This occurred after a recent incident in which the same resident experienced an anaphylactic reaction to nuts, requiring emergency room treatment. The facility was aware of the resident's nut allergy but did not document the severity, develop or implement a care plan for the nut allergy, or ensure that all kitchen recipes were reviewed for food allergies before serving food to residents. On the day of the incident, the resident noticed the presence of mayonnaise on her salad and reported her concern to a CNA. The meal ticket for the resident clearly indicated an allergy to mayonnaise and specified that the salad should be served plain, with no dressing or mayonnaise. Despite this, the meal was not properly checked against the ticket before being served. Staff interviews confirmed that the process for checking meal tickets, especially those marked with yellow to indicate allergies, was not followed as required. The facility's policy required both dietary and nursing staff to verify meal tickets for allergies before serving food, but this protocol was not adhered to in this case.