Patient with known nut allergy given peanut butter in suicide attempt

Central Florida Behavioral Hospital was cited by the Florida Agency for Health Care Administration (AHCA) for deficiencies related to nutritional care, incident reporting, and diets. AHCA found that a patient with a documented nut allergy was given peanut butter and had to be sent to the ER for medical treatment. The patient’s medical documentation claimed that the “patient is depressed and attempted to kill herself by allergic reaction to peanut butter.”

AHCA wrote in the inspection report that during an interview with a patient:

“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.”

AHCA also cited the facility for failing to complete an incident report regarding this suicide attempt. The facility incident report log did not have an incident report and the facility Risk Manager said “she was not aware of the event and staff should have completed an incident report.”

AHCA also cited Central Florida Behavioral Hospital for a violation of regulations for patient diets related to the same incident. AHCA noted that “the facility failed to assure that…patients [were] not served a food item to which the patient was allergic.”

The inspection report did not include a plan of correction.