Failure to Prevent Allergen Exposure in Resident Meal Service
Penalty
Summary
A deficiency occurred when a resident with a documented fish allergy was served a meal containing fish. The resident's electronic medical record included clear documentation of the fish allergy, and the allergy was also noted on the resident's tray card. Despite these precautions, the resident received a tray with fish during supper. The resident did not consume the fish but reported experiencing itching after having the fish in her room, which led to the administration of Benadryl and hydrocortisone ointment for relief. The resident was cognitively intact and communicated her allergy and reaction to staff. Interviews with staff revealed that the dietary aide responsible for serving the meal was made aware of the error and was sent home early that day. The Dietary Manager stated that staff were instructed to highlight food allergies to prevent similar incidents. The facility's policy on menus and nutrition required documentation of resident preferences but did not specifically address food allergies. The administrator confirmed the expectation that dietary staff should be attentive to resident allergies and avoid serving allergenic foods.