Failure to Prevent Allergen Exposure During Meal Service
Penalty
Summary
A resident with a documented allergy to bananas, which causes anaphylaxis, was served Banana Cream Pie during a lunch meal. The resident's clinical record, nutritional assessment, and care plan all indicated a banana allergy, and the meal ticket for the day also noted this allergy. Despite these precautions, the resident received and consumed the dessert containing banana, which led to a severe allergic reaction. The incident required immediate medical intervention, including the administration of epinephrine, after the resident exhibited symptoms such as throat closing, shortness of breath, wheezing, agitation, and anxiety. Interviews with facility staff, including the Dietary Supervisor, Administrator, and Director of Nursing, confirmed that the expectation and policy are to prevent residents from being served foods to which they are allergic. The facility's kitchen documentation outlined responsibilities for cooks and dietary aides to ensure trays are correct and substitutions are made for allergies. However, the process failed, and staff were unable to explain how the resident was served the allergen. The facility's policy on food allergies emphasized steps to prevent exposure, but these were not effectively implemented in this case.