Failure to Follow Dietary Restrictions for Resident with Documented Food Allergy
Penalty
Summary
Facility staff failed to follow a documented dietary restriction related to a food allergy for a resident with multiple diagnoses, including dementia, diabetes, high blood pressure, depression, and anxiety. The resident was not cognitively intact, as noted in the admission MDS assessment. The care plan clearly documented allergies to aspirin, peanuts, and pollen. Despite this, a staff member provided the resident with a peanut butter sandwich upon request, without checking the resident's medical record for allergies. The incident occurred because the staff did not verify the resident's dietary restrictions before providing the food item. Additionally, the allergen binder, intended to keep staff informed of resident allergies, was not updated and was not in its designated location in the snack room at the time of the incident. As a result, the resident consumed a food item containing an allergen, though no signs or symptoms of an allergic reaction were observed following the event.