Failure to Accommodate Documented Food Allergy Results in Resident Reaction
Penalty
Summary
A deficiency occurred when a resident with a documented allergy to mushrooms was served a meal containing mushrooms. The resident's medical records, including the Minimum Data Set, dietary assessment, care plan, and physician orders, all indicated an allergy to mushrooms. However, the resident's meal tickets did not reflect this allergy, and the resident was served chicken with mushrooms hidden underneath, which led to the resident consuming the allergen. Following the ingestion, the resident experienced an allergic reaction, including a red rash on both arms, swelling of the lips, and tingling of the tongue. Nursing staff responded by administering Solumedrol and Benadryl as ordered by a physician. The incident was observed and documented by multiple staff members, who confirmed the presence of mushrooms on the resident's tray and the resident's symptoms after eating the meal. Interviews with facility staff revealed inconsistencies in the communication and documentation of the resident's allergy. The dietician stated that the allergy was not initially reported and that the meal ticket was only updated after the incident. The electronic medical record system did not generate an alert for the allergy, and the dietary supervisor was responsible for ensuring meal tickets matched resident needs. Despite the care plan and orders indicating a mushroom allergy, the failure to update the meal ticket and communicate the allergy resulted in the resident being served an unsafe meal.