Allergies 

Purpose: 

To prevent anaphylaxis and all allergic reactions by identifying and documenting resident allergies accurately. 

Procedure: 

1. Interview and Assessment: 

• Interview the resident and/or family members to determine if there are any allergies to food, drugs, or other substances. 

• Review all clinical documents, including the W-10, Discharge Summary, and History & Physical, to identify any documented allergies. 

2. Documentation: 

• Record all identified allergies on the Physician’s Order Sheet. 

• Ensure allergies are listed on the Medication & Treatment Administration Record (MAR/TAR). 

• Clearly mark allergies on the front of the resident’s Medical Record for easy visibility. 

3. Notification: 

• Notify the Dietary Department immediately if any food allergies are identified to ensure appropriate meal planning and preparation. 

4. Monitoring and Communication: 

• Continually monitor for any signs of allergic reactions and report them immediately to the attending physician. 

• Ensure that all staff involved in the resident’s care are aware of the documented allergies to prevent accidental exposure. 

Compliance and Documentation: 

• Adhere to CMS guidelines and Requirements of Participation for Long-Term Care Facilities regarding allergy documentation and management. 

• Ensure all allergies are documented accurately and updated as necessary in the resident’s care plan. 

• Provide ongoing education and training to staff on the importance of identifying and managing allergies. 

• Conduct regular audits to ensure compliance with this policy and address any gaps in documentation or communication. 

References: 

• Centers for Medicare & Medicaid Services (CMS). State Operations Manual (SOM), Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. 

• CMS Requirements of Participation for Nursing Homes.