Failure to Prevent Serving Allergen-Containing Food to Resident With Documented Tomato Allergy
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a documented tomato allergy was not served tomato products. The resident, admitted in July 2024 with dementia, had an allergy to tomatoes recorded in the electronic health record as of 6/24/2025, with the severity listed as unknown. Despite this documented allergy, a progress note by the Nurse Practitioner dated 10/9/2025 at 10:30 AM states that the resident was noted to have eaten red tomato sauce in their food that afternoon, which they are allergic to, and that the resident required continued close monitoring for any signs and symptoms of allergic reaction. During a surveyor interview on 2/5/2026, the Director of Nursing Services acknowledged that the resident had a documented tomato allergy and should not have been served a tomato product. The deficiency was identified following a community-reported complaint submitted to the Rhode Island Department of Health on 1/27/2026 alleging that the resident experienced an acute medical episode as a result of an allergic reaction. The survey findings, based on clinical record review and staff interview, confirmed that the facility served food containing tomato sauce to the resident despite the known allergy documented in the resident’s record.
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