F0806

D

Failure to Implement and Communicate Food Allergy Information Resulting in Allergic Reaction

Aurora, Missouri Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident’s known food allergies were fully assessed, documented, care planned, and incorporated into diet orders and dietary service processes, resulting in the resident being served a food to which they were allergic. The facility’s own policy required assessment of food allergies upon admission, documentation of all reported allergies in the medical record, notation of severe allergies on the resident profile, and communication of these allergies to the dietitian and food and nutrition services. For this resident, the face sheet listed allergies to beef, beef-derived products, grapes, peanuts, wheat, and Mountain Dew, and the Nursing Admission Data Collection listed allergies to beef-derived products, peanuts, and wheat. However, the admission assessment did not indicate any special nutritional needs, and the comprehensive care plan created on admission did not include any problem, goal, or intervention related to diet or known food allergies.

The resident’s Physician Order Sheet for the admission month contained an order for a regular diet with regular texture and consistency, but it did not address or restrict any of the resident’s documented food allergies. The DON later stated she had entered the allergies into the allergies tab of the electronic medical record but did not add them to the diet order. Staff interviews showed that multiple disciplines relied on diet orders and dietary cards to identify allergies, yet the diet order itself lacked allergy information. The Interdepartmental Notification of Diet policy required written notice of diet orders and changes to food and nutrition services, but in this case, the process was inconsistently followed: staff described both prior use of diet slips and a current expectation of verbal communication with the Kitchen Manager, and there was no clear, single, accurate diet communication tool in place for this resident.

On the day of the incident, the resident, who was cognitively impaired and required supervision for eating, was served a beef taco at lunch. The Kitchen Manager acknowledged he was aware the resident had allergies but stated the diet order did not indicate them and that two dietary cards had been created for the resident—one listing allergies and one without allergies—and the wrong card was used when preparing the tray. A CNA and a CMT both reported seeing two different dietary cards for the resident, one with the correct room number but no allergies and another with allergies but the wrong room number. The CMT observed the resident eating a beef taco and was not aware of any allergies at that time. Later that day, the resident developed vomiting and diarrhea, became unresponsive on the toilet, and was transferred to the hospital. Hospital documentation indicated the resident was admitted for an allergy to beef with a delayed reaction after eating a beef taco at the facility, and the resident received treatment including Benadryl, Solu-Medrol, and Pepcid. Only after the hospital transfer was a care plan created that specifically addressed the resident’s allergies.