Failure to Document and Communicate Food Allergy on Dietary Records
Penalty
Summary
The facility failed to ensure that a resident's documented food allergy to bananas was properly recorded and communicated according to its own policies and procedures. The resident, who was moderately impaired in cognitive skills and dependent on staff for daily care, reported an allergy to bananas that caused mouth swelling. Despite this, the allergy was not documented in the resident's assessment notes, Nutrition Risk Review Form, or admission evaluation. The resident's tray card, which is used by kitchen staff to prepare and deliver meals, did not indicate the banana allergy in the allergy section; instead, bananas were only listed as a dislike, and the allergy section was left blank. During interviews, the Dietary Supervisor confirmed responsibility for updating dietary records and tray tickets with resident allergies but stated that the system would not allow banana to be entered as an allergy, so it was only marked as a dislike. Facility policies require that all reported food allergies be documented in assessment notes and included on tray cards. The failure to document and communicate the banana allergy as required by policy had the potential for the resident to experience an allergic reaction.