Failure to Prevent Exposure to Known Food Intolerance Allergen in Meal Service
Penalty
Summary
The facility failed to ensure that a resident with a documented bell pepper intolerance received food that accommodated this intolerance. The resident’s dietary interview/pre-screen identified a bell pepper intolerance, and the resident’s tray card listed bell peppers as an allergy. The facility’s Fall/Winter Week 2 menu included sweet and sour pork with steamed rice and an Asian vegetable blend for dinner, and the meal was served with a commercially prepared sweet and sour sauce packet. Ingredient information for the sauce showed it contained dried red and green bell peppers. The registered dietician and dietary director confirmed that this sauce packet, which contained bell peppers, was served with the sweet and sour pork meal. Following consumption of the meal, documentation in the resident’s SBAR Summary for Providers indicated that a CNA reported the resident’s heart was beating fast, with recorded vital signs showing a BP of 150/100 and HR of 136, and the resident was sent to the hospital. An interdisciplinary team progress note documented that the resident mixed the sweet and sour sauce into the rice and then reported mouth numbness and upset stomach. The same note indicated that no clinical findings of an acute allergic response were identified during the hospital emergency room evaluation. Staff interviews confirmed that the resident was known to have an intolerance/allergy to bell peppers and that the sauce packet containing bell peppers was served on the resident’s tray, contrary to the facility’s policy on Food Allergies and Intolerances, which requires identification of allergies/intolerances and prevention of exposure to allergens.
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