Failure to Prevent Exposure to Known Food Allergen Resulting in Anaphylaxis
Penalty
Summary
A resident with a documented severe allergy to onions, including airborne exposure, was served a meal containing onions despite clear documentation of the allergy in the medical record, care plan, and on the meal ticket. The resident had previously experienced an anaphylactic reaction to onions, and the allergy was well known to both dietary and nursing staff. On the day of the incident, the resident had selected an alternate meal that should not have contained onions, and the meal ticket specifically indicated the allergy and listed foods to avoid. Despite established facility policies requiring multiple checks of meal tickets for allergies during food preparation and tray line service, the resident was inadvertently served the main meal of taco salad, which contained onions in the salsa mixed with the ground beef. Staff interviews revealed that the process for reading and verifying meal tickets was not properly followed, and the resident's tray was not checked as required before being delivered. The dietary staff involved in meal preparation and tray assembly did not identify the error, and the nursing staff did not catch the mistake before the tray was delivered to the resident. After consuming a portion of the meal, the resident developed symptoms of anaphylaxis, including shortness of breath, tachycardia, low oxygen saturation, and altered mental status. Emergency intervention was required, including administration of epinephrine and transfer to the hospital, where the resident was admitted for further treatment. The incident was attributed to multiple failures in the facility's system for identifying and preventing exposure to known food allergens.