HospitalInspections.org

Based on interview and record review, the facility failed to assure that 1 of 10 sampled patients was not served a food item to which the patient was allergic that resulted in an emergent medical hospital transfer (#1).

Findings:

In an interview with patient #1 on 8/26/14 at 9:15 AM, she revealed that while at the facility she had eaten peanut butter, a food item she was highly allergic to, which sent her to a nearby hospital emergency room for treatment. The patient related her allergy was documented in her medical record, however she was given a container of peanut butter at her request, by the kitchen staff. The patient related the facility did not give her a bracelet to wear indicating her allergy and the dietary staff were unaware of her food allergy.

Review of patient #1's record revealed a voluntary admission with a diagnosis of major depressive disorder, recurrent, severe without psychosis, suicidal ideation and anxiety. A comprehensive assessment part 1-Intake dated 6/17/14 page 1 at 6:00 AM documented, "Patient reports suicidal ideation with a plan to overdose on medication....obsessive thoughts about hurting herself." Page 2 documented Allergies:
yes,"peanuts, walnuts"

The comprehensive assessment-Nursing page 2 dated 6/17/14 at 8:45 AM documented "Allergies & sensitivities -Food : Nuts." The nursing nutritional screening dated 6/17/14 at 8:45 AM documented "Food allergies/intolerance's: Nuts," regular diet. The disposition of patient's medications upon admission, page 7 dated 6/17/15 documented: "Allergies: Nuts."

A history and physical dated 6/06/14 from a previous hospitalization with an addendum for 6/17/14 documented allergies as No Known Drug Allergies (NKDA) and Nuts. Admitting physician orders dated 6/17/14 documented Allergies: Peanuts, walnuts-anaphylaxis. Precaution level: suicidal. Physician orders dated 6/20/14 at 8:15 AM documented Benadryl 50 milligrams (mg) IM (intramuscularly) now, for allergic reaction, and 6/20/14 at 10:20 AM Send patient to ER-call 911."

A Certificate of professional initiating involuntary examination dated 6/20/14 at 11:30 AM, documented a diagnosis of suicidal ideation with supporting evidence "patient is depressed and attempted to kill herself by allergic reaction to peanut butter."

The physician discharge summary dated 6/30/14 documented "She reported that she ate some peanuts, although she was aware that she was allergic to peanuts. She was transported to the emergency room for medical evaluation.....she reported that she had intentionally eaten the peanuts in a suicide attempt."

During an observation of a noon meal service for patients with the facility Director of Nurses (DON) at 12:10 PM on 8/27/14, revealed 2 patient's observed without bracelets for patient identifiers and allergies. The DON related at times patients refuse to wear the hospital bracelet and the kitchen personnel have notebooks of patient picture, dietary information, special diets and identifiers.

Interview with the facility registered dietician at 12:20 PM on 8/27/14 and later with the kitchen manager at 4:30 PM on 8/27/14 revealed the facility has a process in place if a patient comes to the tray line to ask for food items. They related dietary personnel pull their books of patient names, special diets and allergies to verify what they are able to provide for patients. They related dietary personnel are not allowed to give out food items without verifying the book. They were not aware of any employee providing peanut butter to a patient with a known and documented nut allergy.

The facility distributed peanut butter to a patient with a known allergen whose medical condition was adversely affected, thereby failing to meet the special needs of the patient.