**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility was aware of Resident (R) 7's nut allergy but failed to document severity of nut allergy, failed to develop and implement a care plan for R7's nut allergy and failed to assure all recipes cooked in the kitchen were on the templates reviewed for food allergies before providing food to residents. The deficient practice resulted in harm to R7 who received food that contained nuts and having an anaphylactic response requiring transport to the emergency room for treatment. Findings Include: According to the United States Department of Agriculture (USDA) A food allergy is a potentially serious response to consuming certain foods or food additives. For those who are sensitive, a reaction can occur within minutes or hours, and symptoms can range from mild to life-threatening. The nine leading causes of food allergies identified in the US are milk, eggs, fish, shellfish, tree nuts, peanuts, wheat, soybeans, and sesame. USDA's Food Safety and Inspection Service (FSIS) and the U.S. Food and Drug Administration (FDA) both have laws requiring that all the ingredients in a food product be listed on the food label. https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/food-allergies-big-9 Review of facility Event Report dated 03/19/25 for R7 submitted to State Agency (SA) revealed she ate a facility baked and provided dessert at about 01:00 PM and experienced an anaphylactic (severe allergic reaction) response to it. The following information was provided in the Event Report: On 3/19/25 at about 1300 (01:00 PM), resident (R7) called stating that she may have eaten something that she is allergic to. Noted resident's periorbital (refers to the tissues surrounding or lining the orbit of the eye) are slightly reddened. Called MD right away at 1300 (01:00 PM). Received and carried out order for Benadryl 25mg PO Q6 hours PRN (as needed). Called SRN (Nursing Supervisor) to get the Benadryl from the E-kit. VS (vital signs) at 1303 (01:03 PM) are 97.4F (temperature)-87 (pulse)-20 (respiratory rate)-130/67 (blood pressure)-94% (Oxygen saturation) on RA (room air). Noted resident (R7) was anxious and stayed with the resident. Administered the PRN (as needed) Benadryl as ordered upon receipt. Resident (R7) tolerated it. Resident (R7) c/o (complained of) itch to eyes and back. Noted periorbital swelling. Noted desaturation to 84% on RA. Administered oxygen via NC (nasal cannula) at 5L/min. O2 (oxygen) sat (saturation) increased to 94-96%. Updated MD at 1337 (01:37 PM). Received and carried out order to send to ER (emergency room) for anaphylactic shock. Writer called 911 at 1340 (01:40 PM) to give report. SRN (Nursing Supervisor) called the resident's son, at 1341 (01:41 PM) to update him and is agreeable with sending resident to the ER. Fire Department arrived at about 1345 (01:45 PM) followed by ambulance. Per ambulance, not sure what hospital they will go to yet. Resident left via ambulance gurney at 1350 (01:50 PM). On 04/23/25 review of R7's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE] and her diagnoses include, but are not limited to, other intervertebral disc degeneration, thoracolumbar region; muscle weakness (generalized); unspecified asthma, uncomplicated; essential tremor; and dysphasia (impairment in the production of speech resulting from brain disease or damage). Review of R7's Minimum Data Set with an Assessment Reference Date (ARD) of 02/19/25 revealed her Brief Interview for Mental Status (BIMS) was 15 which indicates she is cognitively intact. Review of R7's care plan, initiated 02/13/25, did not include a care plan for R7's allergies and need for a therapeutic diet to exclude the food items R7 is allergic to, and did not include interventions to address what to do if R7 is exposed to allergen (food items). On 04/23/25 at 10:53 AM an interview was conducted in the kitchen with the Kitchen Manager (KM). Inquired of KM if R7 had food allergies on her diet and KM was unsure.KM stated following R7's incident, the facility stopped ordering nut items, they are currently a nut free facility. Tour of the kitchen found all nut items had been disposed of and no nut food items were found in the kitchen. Inquired about food item that had been cooked in the kitchen that had been given to R7. KM stated the facility was using a recipe (Jello Cream Cheese Square dessert), from 2019 that included nuts, but they no longer include nuts in this recipe after R7's allergic reaction. R7 was on transmission-based precautions, therefore, on 04/23/25 at 12:44 PM a phone interview was conducted. Inquired if resident had notified facility staff of her nut allergy, R7 stated she gave the list to the dietician and the dietician took notes. Dietician also asked the resident about her food preferences. R7 reported she ate an ice cream dessert with a cookie on the bottom and that was where the nuts were. R7 stated her nut allergy is her most violent allergy. R7 stated on her meal tray that day there was nothing indicating there was anything with nuts on her tray. R7 believes it was hidden with a very small amount in the cookie. R7 stated she reads all the labels on food before she eats anything because it can be lethal. On 04/23/25 at 02:28 PM met with the Administrator in the conference room and requested a copy of admission documents for R7. On 04/23/25 at 03:00 PM an interview was conducted in the conference room with Head Nurse Registered Nurse (RN)3. Inquired if the resident who has a severe allergy to nuts would have a care plan for this and she said yes. Inquired if R7 had a care plan for her nut allergies prior to her being exposed to nuts and she confirmed R7 did not have a care plan for her nut allergy. On 04/23/25 at 03:15 PM Administrator provided copies of requested admission forms filled out for R7. On 04/23/25 at 03:20 PM an interview was conducted in the conference room with the Day Shift Supervisor, RN4. Inquired of RN4 if she did R7's admission intake. RN4 stated she filled out the Pre-admission Notification form for R7. RN4 stated she had received admitting information from hospice which included R7's allergies but not the reaction to the allergens. Inquired who receives the Pre-admission Notification form and RN4 stated the team which included the DON, Social Worker, Doctor, Dietician, etc. Inquired if RN4 spoke with R7 and asked her reaction to her allergies (medications and foods) and she denied this stating this form is for pre-admission and the resident was not at the facility at that time. On 04/23/25 interviewed Dietician at 03:50 PM in the conference room. She provided a copy of R7's updated care plan that was initiated on 03/20/25. Inquired if dietician would initiate a care plan for resident's diet that included restrictions due to allergies and dietician stated she does not open any care plans for food allergies unless they (the resident) are not eating or are losing weight. Dietician stated normally she does not open the care plan for allergies unless it involves their nutritional intake. Dietician stated she talked to resident on 02/13/25 and resident stated she swells up if she eats nuts. Dietician was unsure if she shared this information in the IDT (Interdisciplinary Team) note. Dietician stated she jotted it down on her notes of what resident was stating such as mustard makes her sick, nuts make her swell up. Dietician stated this information was not shared in resident's chart (EHR or hard chart) or with the IDT in her assessment. Dietician explained food item served to R7 that caused the allergic reaction was not on the template used that would show all the ingredients used in the recipe, which would include nuts and that was how the dessert was able to be placed on R7's meal tray. Review of R7's admission documents revealed the Nursing admission Screening History dated and timed 02/13/25 at 14:42 (02:42 PM) did not include any reaction to R7's allergies for prescribed medications and food items resident is allergic to. A review of R7's admission orders dated 02/13/25 included R7's diet but no food restrictions related to her food allergies. R7's allergies were listed and included Famotidine, Penicillin, Phenobarbital, Sulfamethoxazole Trimethoprim, Levaquin, mayonnaise, mustard, nut. The admission orders included R7's allergies but date last reaction and specific reaction was left blank for all the medication and food allergies even though the form states List/circle specific reactions (DO NOT LEAVE BLANK): ______________ or anaphylaxis/rash/hives/wheeze/SOB (shortness of breath)/dizziness/CP/syncope (fainting)/N/V (nausea/vomiting) abdominal pain/diarrhea/bleeding/UNK (unknown). Review of Nutrition Assessment for R7 dated 02/25/25 included R7's diet 2/13/25: Regular diet, chopped texture, Regular thin liquids consistency, for Dysphagia; Dietician may order oral supplements as needed. 2/15/25 Regular diet, chopped texture, Regular thin liquids consistency, May have bread products for Dysphasia, unspecified. R7's Nutrition Assessment listed R7's allergies as Multiple nuts, Mayonnaise, mustard, spices, Curry, all salad dressings. R7's Nutritional Assessment did not include her reactions to her allergies. Review of R7's IDT Conf. Notes -V2 dated and timed for 02/14/25 at 08:58 did not include any mention of R7's allergy reaction to her list of medication and food allergies. A phone interview was conducted with RN5 on 04/24/25 at 09:21 AM. RN5 confirmed she was the nurse who did the admission intake for R7. Inquired if she inputted R7's allergies into the EHR and she denied this. Concurrent record review and interview with RN5 revealed Head Nurse RN6 had inputted R7's allergies in the EHR which included nuts. Inquired if other facility staff or R7's family told her R7's nut allergy is bad to the point the resident swells up and RN5 could not recall. A phone interview was conducted on 04/24/25 at 10:28 AM with R7's attending physician. Inquired if Medical Doctor (MD) was aware of R7's nut allergy and he confirmed he was. Inquired if R7 or her son had told MD of her reaction to nuts and he denied this, stated the allergy information was provided by hospice. Inquired of MD if he would have ordered medications such as Benadryl and an Epi pen prn (as needed) to have on hand if he knew of her allergy reaction to nuts and he confirmed this and stated these are in the e-kit (emergency kit). MD stated he believed R7 was exposed to trace amounts of nuts in the dessert she ate. On 04/24/25 at 03:11 PM an interview was conducted with Head Nurse RN6 in the conference room. Inquired of RN6 if allergies are included in the baseline care plan when residents are admitted . RN6 stated allergies are included in the allergy tab in resident's EHR but never put in the baseline care plan. RN6 confirmed she inputted R7's allergies into the EHR. Inquired if RN6 went over allergies and her reactions with R7 and RN6 denied this. RN6 stated they base it upon the discharge list that comes with the resident, it has a list and sometimes has information like GI upset or unknown response. Inquired about R7's care plan and RN6 stated the nut allergy was added to R7's care plan after she (R7) had the severe allergic response. Concurrent review of R7's baseline care plan revealed there is a diet section which only included R7's diet, not that the R7 has an allergy to nuts. On 04/24/25 at 04:45 PM an interview was done with R7 in her room at the bedside. Inquired if resident had told any facility staff about her reaction to her nut allergy. Resident explained she had met with a lady, believes she was a dietician, could not remember her name but explained she was very professional and knowledgeable and took notes down of her food preferences and resident explained her nut allergy was her most dangerous allergy. Inquired if any of the nurses inquired of her allergy reactions and resident said no. Inquired how long resident has had the allergy to nuts and she stated, since I was a baby, that her mother was afraid she would lose her because of it. On 04/25/25 at 09:20 AM inquired of Kitchen Manager (KM) for a copy of the Jello dessert recipe and received a copy of facility's recipe for Jello Cream Cheese Square. KM stated they use this recipe but no longer add nuts to the recipe since they have gone nut free. Review of the recipe found it contained Walnuts (minced) - 4 cups. On 04/25/25 at 10:09 AM an interview was conducted with the DON in the conference room. Reviewed R7's admission paperwork with DON who confirmed the nurse should have circled or wrote the reaction to R7's allergies on the admission Orders form. Inquired if nurses are expected to interview residents when they are admitted and ask what their allergy reactions are and DON stated the expectation was not to interview residents about their allergies, the facility would avoid it, for example if the resident were allergic to penicillin the resident would not get this medication. DON stated they would use the discharge summary as the communication from the hospital and enter the information into PCC (Point Click Care, electronic health record software). PCC will alert the doctor if they order a medication the resident is allergic to. Inquired who the pre-administration form is sent to, and DON stated everyone on the team. Review of R7's physician progress note dated and timed for 03/19/25 at 23:20 (11:20 PM) states: Note Text: Progress note: Subjective: Patient was transferred from Name of Nursing Facility to Name of Acute Hospital emergency room for anaphylaxis after she inadvertently consumed nuts that were in her Jell-O pudding dessert. She had periorbital swelling, shortness of breath, and desaturation. Upon transfer by EMS personnel, patient received epinephrine and diphenhydramine IV pushes. She did receive methylprednisolone IV in the emergency department. Allergic reactions completely resolved. Patient to return back to the nursing facility. Objective: Prior to transfer to Name of Acute Hospital emergency room: Vital signs: Temperature 97.4. Pulse 87. Respiratory rate 20. Blood pressure 130/67. Oxygen saturation 94% on room air. Subsequent desaturation to 84% room air. 94% on 5 L/min via nasal cannula. General: Patient appears to be in distress. HEENT: Periorbital edema. Lungs: Diminished. Cardiovascular: Regular rate and rhythm. Abdomen: Nondistended. Bowel sounds present. Extremities: No edema. No clubbing. No cyanosis. Neurologic: Unchanged. Assessment: Anaphylaxis secondary to inadvertent consumption of nuts with her Jell-O pudding dessert. Patient has underlying history of allergies to nuts. Allergic reaction has resolved after interventions which consists of diphenhydramine, epinephrine, and methylprednisolone IV. Patient is medically stable to be transferred back to Name of Nursing Facility. Plan: Patient returning from Name of Acute Hospital emergency room back to Name of Nursing Facility. Avoid administration of nuts in which patient is allergic to.