Failure to Prevent Shellfish Allergen Exposure in Resident Meal Service
Penalty
Summary
Facility staff failed to prevent an allergic reaction for a resident with a documented severe shellfish allergy when the resident was served and consumed lobster ravioli provided by the facility. The resident’s electronic health record listed a shellfish allergy categorized as a food allergy with a severe reaction manifestation and severity, and this allergy was also reflected in the resident’s care profile. The resident had a cognitive communication deficit and was assessed as moderately impaired in cognition for making daily decisions, scoring 12 out of 15 on the BIMS. Despite these documented conditions and allergy information, the facility’s dinner menu for the skilled nursing floor included lobster ravioli, and the resident received and ate 100% of this meal. Around the time of the evening meal, the resident activated the call bell, and an LPN responded. The resident reported difficulty breathing and stated that the dinner served was shellfish, to which he was allergic. The LPN obtained vital signs, which were documented as blood pressure 124/74, heart rate 121, temperature 97.8°F, and oxygen saturation 96% on room air. Although the vital signs were noted to be within normal limits, the resident continued to report trouble breathing. The LPN attempted to contact the on-call physician service but was unable to reach a provider and then called 911 to have the resident transferred to the emergency room for further evaluation and medical management. The LPN later confirmed that the lobster ravioli had come from the facility. At the hospital, the resident was evaluated for acute onset shortness of breath and undifferentiated shock after exposure to shellfish, briefly requiring vasopressor support. The hospital documentation noted a differential diagnosis of bronchiolitis versus allergic reaction, and the resident was treated with 25 mg of Benadryl and admitted for further evaluation. Facility interviews and documentation indicated that the dietary department had a process in which resident food allergies were to be communicated via a notify form and posted allergy lists in the pantry, and that dietary aides were expected to reference these lists when plating meals. The dietician stated that the resident knew he ordered lobster ravioli and that the dietary aide should have caught the shellfish allergy, while a dietary aide described relying on the posted allergy list when plating meals. Despite these procedures and the posted allergy information, the resident with a documented severe shellfish allergy was able to order, receive, and consume lobster ravioli, resulting in an allergic reaction that required emergency treatment and hospitalization and was cited as Immediate Jeopardy with harm.
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