F0806

D

Failure to Prevent Serving Allergen-Containing Food Despite Documented Allergy

Thornton, Colorado Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that food served accommodated a resident’s documented allergy, resulting in the resident being served and ingesting pineapple despite a known pineapple allergy. Facility policy on Food Allergies and Intolerances, revised August 2017, states that residents with food allergies are to be identified upon admission, have allergies documented in the care plan, and be offered appropriate substitutions, with steps taken to prevent exposure to allergens. For the resident involved, the comprehensive care plan initiated in mid-January identified allergies to pineapple and wool, and the care plan report listed pineapple as an allergy and included an intervention for staff to honor food preferences, although it did not document specific food likes and dislikes.

The resident, an older adult with diagnoses including severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness, was cognitively intact with a BIMS score of 15 and required set-up or clean-up assistance with eating. On an evening in January, nursing documentation shows that pineapple was present on the resident’s dinner tray even though the resident had a documented pineapple allergy. The progress note states the resident ate two pieces of pineapple before the error was recognized and the pineapple was removed. The resident’s representative reported that the allergy was documented in the medical record and on the meal ticket, yet pineapple was still served, and that the resident became upset and did not understand how this occurred.

According to the facility’s own root cause analysis, the dietary aide responsible for serving food did not correctly review the resident’s meal card and failed to note the highlighted pineapple allergy, placing pineapple on the tray as dessert. The CNA delivering the tray identified the pineapple only after the resident had already eaten two pieces. Interviews with the dietary manager, dietary aide, cook, RD, CNA, RN, and DON consistently described a system in which resident allergies are entered into an electronic system, printed on meal tickets, and highlighted so that kitchen and nursing staff can verify trays before service. However, in this incident, staff did not adequately review or follow the meal ticket information, and subsequent resident council notes documented ongoing resident concerns that CNAs were not following meal tickets correctly and were not consistently asking residents for their meal choices.

Resident council meeting notes from late January and late February further describe meal service concerns, including reports that CNAs blamed the kitchen for meal mistakes and did not correct issues when errors occurred, and that meal tickets were not being followed correctly by CNAs on a specific unit. These resident reports indicate that, beyond the single documented pineapple incident, residents perceived ongoing problems with adherence to meal tickets and proper verification of meals against documented diets and allergies. The deficiency is thus centered on the facility’s failure, in at least one case, to prevent exposure to a known food allergen despite clear documentation and an established process intended to identify and avoid such allergens.