Other·June 13, 2024

F806 §483.60(d) Food and drink Each resident receives and the facility provides— §483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences; On 4/29/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the annual Recertification Survey and investigate a complaint regarding quality of care and dietary services. The facility failed to ensure Resident 147 was not given food containing allergens (a substance that causes an allergic [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances] reaction) when: 1. Certified Nursing Assistant 2 (CNA 2) did not inform a licensed nurse (a Licensed Vocational Nurse [LVN] or Registered Nurse [RN]) of Resident 147's request for a snack on 4/14/2024 which would then require a licensed nurse to complete a Diet Order and Communication Form (DOCF- a form designed to ensure clear communication between residents, nurses and dietary staff that indicates dietary preferences and restrictions to promote safe food distribution) prior to providing food to Resident 147. 2. Dietary Staff 1 (DS 1) did not first obtain from CNA 2 a DOCF to ensure the provided peanut butter and jelly sandwich did not violate Resident 147's dietary restrictions, prior to providing CNA 2 with a peanut butter and jelly sandwich which was then given to Resident 147. As a result, Resident 147 was given a peanut butter and jelly sandwich causing Resident 147 to experience shortness of breath, requiring Resident 147 to be transferred to the General Acute Care Hospital (GACH); and had the potential to resulted in life-threatening conditions such as anaphylactic shock (severe allergic reaction including closure of airways), and or death for Resident 147. A review of Resident 147's Admission Record indicated the facility originally admitted Resident 147 on 4/8/2024 with diagnoses that included hemiplegia (inability to move one side of the body) and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (disruption of blood flow to the brain due to the lack of blood supply and oxygen to the brain) affecting the left dominant side, atrial fibrillation (an irregular and often very rapid heart rhythm), and difficulty in walking. The Admission Record further indicated that Resident 147 had an allergy to nuts. A review of Resident 147's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 4/11/2024 indicated Resident 147's cognition (ability to think and make decisions) was intact. The MDS further indicated that Resident 147 needed supervision when eating. A review of Resident 147's Allergy Reported dated 4/8/2024 indicated that Resident 147 is allergic to nuts. A Review of Resident 147's Nutritional Assessment dated 4/11/2024 timed at 11:06 a.m. indicated Resident 147 is allergic to nuts. A review of Resident 147's Change in Condition (COC- when there is a sudden change in a resident’s health or condition) Form dated 4/14/2024 timed at 10:55 a.m., indicated that "Resident (Resident 147) has allergy to peanut, ate peanut butter sandwich and complaining of shortness of breath now." Further review of the COC form indicated Resident 147 requested for a tuna sandwich, but mistakenly received a peanut butter and jelly sandwich. The COC form indicated that Resident 147 then complained of difficulty with breathing after Resident 147 had taken a bite of the peanut butter and jelly sandwich. Resident 147 was placed on two (2) liters (L- unit of measure) of oxygen via nasal cannula (a device used to deliver supplemental oxygen [a treatment that provides residents with extra oxygen to breathe in] or increased airflow to a resident in need of respiratory help) and was given STAT (an immediate order) Benadryl (a medication used to treat allergies, itching and the common cold [an illness affecting a person's nose and throat]) 25 milligrams (mg- unit of measure), Claritin (a medication that treats allergies and hives [raised red bumps on the skin]) 10 mg and Pepcid (a medication that can be used to treat an allergic reaction) 40 mg by mouth. Resident 147 was monitored and transferred to the GACH at 12:40 p.m. A review of Resident 147's Physician Orders dated 4/14/2024 at 11:30 a.m. indicated the following orders: 1. STAT Benadryl 25mg one time for allergy to peanut; route not specified. 2. STAT Claritin 10 mg one time for allergy to peanut; route not specified. 3. STAT Pepcid 40 mg one time for allergy to peanut; route not specified. A review of Resident 147's GACH Emergency Department (ED- area in a hospital that provides 24-hour emergency care to patients in need of urgent medical attention) Provider Notes dated 4/14/2024 at 2:15 p.m. indicated that Resident 147 experienced a sudden onset of throat tightening after being given a peanut butter sandwich which Resident 147 was told was a tuna sandwich. The ED Provider note further indicated that Resident 147 is allergic to "nuts [peanuts] and peanut butter" and has had anaphylaxis (life threatening allergic reaction) in the past. A review of Resident 147's GACH After Visit Summary dated 4/14/2024 indicated Resident 147 is allergic to "nut (peanuts) and peanut butter (all nuts)" both of which have been identified since 5/23/2016. During an interview on 5/1/2024 at 10:13 a.m. with CNA 2, CNA 2 stated that it is the facility's process that when a resident requests for a snack, a DOCF must be filled out and signed by a licensed nurse before the kitchen staff can provide the requested food. CNA 2 stated that on the morning of 4/14/2024 (unable to recall specific time), Resident 147 asked CNA 2 for a sandwich. CNA 2 stated that CNA 2 then went to the kitchen and asked DS 1 for a "tuna sandwich". When CNA 2 was asked if CNA 2 provided a DOCF to DS 1 on 4/14/2024, CNA 2 stated CNA 2 forgot. CNA 2 stated that CNA 2 was not aware that DS 1 provided a peanut butter and jelly sandwich instead of the requested tuna sandwich. CNA 2 stated that CNA 2 forgot to inform Registered Nurse 1 (RN 1) of Resident 147's request for a tuna sandwich so that RN 1 could complete a DOCF for Resident 147. CNA 2 stated that after giving Resident 147 the peanut butter and jelly sandwich, which CNA 2 believed to be a tuna sandwich at the time, Resident 147 took a bite of the peanut butter and jelly sandwich. CNA 2 stated that Resident 147 threw the sandwich in the trash after taking a bite and informed CNA 2 that the sandwich was a "peanut butter" sandwich which was "bad for him (Resident 147)". CNA 2 stated that DS 1 provided CNA 2 with the "wrong sandwich". CNA 2 stated it is important that staff completed a DOCF when a resident requests food because the form acts as a safety check for a resident's allergies. During a concurrent interview and record review on 5/1/2024 at 10:30 a.m. with the DS (Dietary Supervisor), the DS reviewed the facility's "Food & Nutrition Services: Diet Order & Communication Form (DOCF)" last revised on 12/6/2019. The DOCF indicated an area for resident allergies to be filled out and documented by the licensed nurse. DS stated that it is the process of the facility that when a food request is made by a resident to a Certified Nursing Assistant (CNA), the CNA is then responsible for informing a licensed nurse (LVN or RN) of the resident's request. DS stated that the LVN or RN will then complete the DOCF after first confirming (though chart review) the resident's dietary restrictions. DS stated that upon completion of the DOCF by a licensed nurse, the licensed nurse can then provide the DOCF to a CNA who in turn can provide the DOCF to a kitchen staff. The DS stated that kitchen staff will then have to review the DOCF before providing the CNA with the requested food. The DS stated it is important to follow the facility protocol and complete a DOCF because it is a safety check for the resident and the DOCF is used to identify potential food concerns such as food allergies. The DS stated that on 4/14/2024 (unable to recall exact time) CNA 2 requested a sandwich from DS 1. DS stated that DS 1 believed the sandwich request was intended for CNA 2 which is why DS 1 provided CNA 2 with a sandwich without a DOCF. DS stated that the incident that took place on 4/14/2024 where Resident 147 was provided a peanut butter sandwich that Resident 147 was allergic to, could have been prevented if facility staff had followed protocol and completed a DOCF. The DS stated that providing a resident with foods they are allergic can possibly result in the death of a resident. During an interview on 5/1/2024 at 1:48 p.m. with Resident 147, Resident 147 stated, on 4/14/2024 (unable to recall specific time), Resident 147 requested a snack from CNA 2 and was given a sandwich that CNA 2 stated was a tuna fish sandwich. Resident 147 stated that after taking two bites of the sandwich, Resident 147 "immediately had labored (difficult or impaired) breathing." Resident 147 stated that CNA 2 had given him a peanut butter and jelly sandwich which caused severe itching to the roof of Resident 147's mouth and made Resident 147's throat start to swell (increase in size) up. Resident 147 further stated "I was having extreme difficulty breathing and I was actually panicking, wondering if that was going to be it (death) for me." During an interview on 5/1/2024 at 3:08 p.m. with RN 1, RN 1 stated that on 4/14/2024 (unable to recall specific time), CNA 2 did not inform RN 1 of Resident 147's request for a sandwich or snack. RN 1 stated that if a resident makes a food request from a CNA, the CNA is supposed to inform a licensed nurse so that the licensed nurse can fill out a DOCF. RN 1 stated that on 4/14/2024, CNA 2 went directly to the kitchen and asked DS 1 for a sandwich intended for Resident 147. RN 1 stated that CNA 2 then gave the obtained sandwich to Resident 147 believing the sandwich was a tuna sandwich. RN 1 stated that CNA 2 informed RN 1 that Resident 147 took "one bite" of the sandwich and stated that the sandwich was a "peanut butter" sandwich. RN 1 stated that RN 1 reviewed Resident 147's chart for the resident's allergy list and noted nuts listed. RN 1 stated that upon realizing Resident 147's allergy to nuts, RN 1 informed Resident 147's attending physician. During a follow-up interview on 5/2/2024 at 9:21 a.m. with Resident 147, Resident 147 stated that upon admission to the facility on 4/8/2024, Resident 147 was asked by facility staff (unable to recall exact staff member) about Resident 147's allergies. Resident 147 stated that Resident 147 had a nut allergy, specifically mentioning a peanut allergy. During an interview on 5/3/2024 at 2:10 p.m. with the Director of Nursing (DON), DON stated that it is the facility process that if and when a resident request for a snack or food, that request must be relayed to a licensed nurse. The DON stated the licensed nurse must then fill out a DOCF only after the licensed nurse has verified the resident's dietary restrictions. DON stated that on 4/14/2024, CNA 2 did not follow the facility protocol for requesting food on behalf of Resident 147. The DON stated that CNA 2 went directly to the kitchen without a completed DOCF to request a sandwich for Resident 147. The DON stated that DS 1 provide a peanut butter and jelly sandwich to CNA 2 without first obtaining a completed DOCF. The DON stated that as a result of CNA 2 and DS 1 failure to follow facility protocol related to a resident's request for food, Resident 147 experienced shortness of breath after taking a bite of the peanut butter and jelly sandwich provided to Resident 147 on 4/14/2024. The DON stated it is important for staff to be aware of a resident's allergies when providing food to a resident. The DON stated a resident can go into anaphylactic shock if given food a resident is allergic to. A review of the facility's policy and procedure (P&P) titled, "Food Allergies and Intolerances," last reviewed 1/11/2024, indicated, "Residents with food allergies and or intolerances are identified and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s)." The policy further indicates that Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat. The facility failed to ensure Resident 147 was not given food containing allergens when: 1. CNA 2 did not inform an LVN or RN of Resident 147's request for a snack on 4/14/2024 which would then require a licensed nurse to complete a DOCF prior to providing food to Resident 147. 2. DS 1 did not first obtain from CNA 2 a DOCF to ensure the provided peanut butter and jelly sandwich did not violate Resident 147's dietary restrictions, prior to providing CNA 2 with a peanut butter and jelly sandwich which was then given to Resident 147. As a result, Resident 147 was given a peanut butter and jelly sandwich causing Resident 147 to experience shortness of breath, requiring Resident 147 to be transferred to the GACH; and had the potential to resulted in life-threatening conditions such as anaphylactic shock, and or death for Resident 147. The above violation had a direct relationship to the health, safety, or security of Resident 147.