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Based on medical record review, documentation review and staff interview, the dietary staff did not ensure the correct meal tray was delivered to Patient #1.

Findings include:

Review of Policy and Procedure #S20, Patient/Resident/Participant Client Identification last reviewed 04/18 revealed patient identification is a fundamental responsibility of every staff member in order to provide correct care/service to the correct patient.

Review of Physician Assistant (PA) note dated 9/24/18 at 06:26 PM revealed the patient ingested pineapple this evening. Pineapple is listed as an allergy in the chart.

Review of Physician Discharge summary dated 09/25/18 at 08:36 AM revealed the evening of 09/24/18 the patient received a fruit cup which had pineapple in it causing him to have an allergic reaction requiring Decadron, epinephrine, racemic epi, and Benadryl.

Review of meal tickets revealed a tray from the previous patient was delivered to Patient #1 the evening of 9/24/18.

Interview with Staff (Z), Hospitality on 11/29/18 at 11:30 AM revealed at the time of dinner tray delivery on 9/24/18, Patient #1 was not identified as required by facility policy to ensure the correct patient received the correct tray.

Interview with Staff (A) and (B). Regulatory Compliance on 09/30/18 at 03:30 PM verified the above findings.

Based on observation, document review and interview, facility staff did not consistently check 1 of 3 emergency carts in accordance with facility policy.

Findings include:

Review of policy and procedure GM4, Code Team /Pediatric Code Team Interdisciplinary Policy last reviewed 09/2016 revealed emergency carts and equipment will be maintained and checked every 24 hours.

Review of Emergency Equipment and Blue Alert Cart checklist dated 11/2018 for Emergency Cart #2 on unit 4200 revealed 9 of 27 days were missing documentation to indicate the emergency equipment was checked.

Interview with Staff (C), Regulatory Compliance on 11/28/18 at 12:00 PM verified the above findings.