Failure to Prevent Allergen Exposure in Resident Meals
Penalty
Summary
The deficiency involves the facility’s failure to prevent a resident with documented food allergies from being served foods containing known allergens. The resident had allergies recorded in the EMR, care plan, diet type report, and tray card to dill, dill oil, mushrooms, ketchup, lactose, radishes, acetic acid (vinegar), and mayonnaise. The resident was cognitively intact with a BIMS score of 15 and reported that their mouth and tongue would swell when consuming allergens. Despite this, the resident stated they had spoken with the Dietary Manager multiple times and continued to receive foods containing allergens. Surveyors observed that during a noon meal, the resident was served a cheeseburger and potatoes with a sealed packet of mayonnaise on the tray, and a CNA offered ketchup, which the resident refused. The CNA confirmed she served the tray, offered ketchup, and that a mayonnaise packet was present, and she was unable to locate the resident’s tray card at that time. The Dietary Manager confirmed the resident’s allergies to ketchup and mayonnaise and acknowledged that mayonnaise should not have been on the plate and ketchup should not have been offered. Later, during the evening meal, the resident was served a cheeseburger, creamy coleslaw, cubed potatoes, and cookies, with the coleslaw in contact with other foods on the plate. Review of the coleslaw recipe showed it contained mayonnaise and vinegar, and the Registered Dietitian confirmed it was an error that the resident received mayonnaise and creamy coleslaw despite allergies documented in Meal Tracker and on the tray slip.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.