Failure to Develop Comprehensive Care Plan for Resident Allergies
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered care plan to address a resident's multiple food and drug allergies. The resident, who was cognitively intact and independent in activities of daily living, reported having numerous allergies, including to fish and seafood. Despite this, he experienced an allergic reaction after being served fish in the dining room. Although the kitchen staff removed the fish from his plate upon his reminder, they did not provide a clean plate, and he subsequently had a reaction requiring emergency intervention with an EpiPen and Benadryl. Interviews with staff revealed that while allergies were documented on meal tickets, the MAR, and in CNA tasks, there was no care plan in place specifically addressing the resident's allergies. The Unit Manager and MDS nurse both confirmed that allergies were not included in the care plan, and the Director of Nursing stated that the facility did not care plan for allergies. Review of the resident's clinical record showed no evidence of a care plan for allergies, no physician orders, and no documentation of the administration of Benadryl or EpiPen, nor any nursing assessment or follow-up after the allergic reaction. Facility policy required a comprehensive care plan to be completed and updated as changes occurred, with input from relevant staff and the resident. However, in this case, the care plan did not address the resident's significant allergy history, and there was a lack of documentation and follow-up regarding the allergic event. The deficiency was identified through interviews, record review, and facility documentation, confirming the absence of a comprehensive care plan for the resident's allergies.