Failure to Prevent Allergen Exposure Resulting in Resident Hospitalization
Penalty
Summary
A deficiency occurred when a resident with a documented allergy to fish was served a meal containing tilapia. The resident, who had a history of anaphylaxis and other medical conditions including cognitive communication deficit and muscle weakness, consumed the fish during lunch. The resident was not aware the meal contained fish until after eating it, which led to the onset of itching and difficulty breathing. Staff interviews and facility investigation revealed that both the cook and the certified nurse aide involved in preparing and serving the meal did not check the diet ticket for allergies prior to sending and serving the tray. The cook had previously received a written warning and corrective education for a similar incident involving another resident and a known allergen. The failure to check the diet ticket and confirm the resident's allergies directly resulted in the resident being exposed to a known allergen. Following the meal, the resident developed symptoms consistent with anaphylactic shock, including altered consciousness, facial swelling, difficulty breathing, and low oxygen saturation. Emergency medical services were contacted, and the resident required hospitalization in the intensive care unit for treatment of anaphylaxis. The incident was confirmed through record review, staff interviews, and medical documentation.