Failure to Monitor and Approve Outside Food Leads to Resident's Death
Summary
The facility failed to ensure that a resident with difficulty swallowing and at risk for aspiration received care and monitoring of food consumption within the guidelines of the diet order. The facility did not implement its policy and procedure for food brought in from outside sources, which required that such food be shown to the Charge Nurse for approval to ensure it was within the diet order. Additionally, the facility did not provide the resident's family with the information sheet about bringing in food for a resident, nor did it ensure ongoing communication and coordination among staff to support the resident's nutritional well-being and safety. As a result, the resident consumed regular textured food brought in by a family member, which was not consistent with the prescribed pureed diet. The Certified Nursing Assistant (CNA) observed the resident eating the food but did not report it to the Charge Nurse. Subsequently, the resident became congested, had difficulty breathing, and became cyanotic. The resident became unresponsive and required cardiopulmonary resuscitation (CPR) but was pronounced dead shortly after. Interviews and record reviews revealed that the facility staff did not follow the established procedures for monitoring and approving outside food. The resident's diet and diet texture were not discussed during the initial interdisciplinary team (IDT) conference, and the family was not educated on the resident's special diet. The CNA did not intervene or report the incident when the resident was observed eating the wrong food texture, leading to the resident's adverse health event and subsequent death.
Removal Plan
- The Minimum Data Set (MDS) Nurse reviewed the diet orders of all current residents to determine if their diet texture and fluid consistency needed to be clarified with the physician. The MDS Nurse completed the clarification of diet orders.
- The Nurse Consultant provided an in-service to six Interdisciplinary Team (IDT) members to inform the resident's family, during the initial IDT meeting and subsequent IDT meetings as needed, about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The resident's family would be asked to sign a form acknowledging they received this information. The DON was the only remaining IDT member who would be provided with an in-service by the Nurse Consultant upon their return to work.
- The IDT reviewed current residents who were on a therapeutic diet and informed their family members via telephone conversation about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The information was provided using the family members' native language. The IDT members documented in the resident's chart that the family has been informed.
- Consultant provided an in-service to Registered Nurses (RNs), Licensed Vocational Nurses (LVN), Certified Nursing Assistants (CNA) and Restorative Nurse Aides (RNA), regarding the facility's policy on Food for Resident from Outside Sources and the different diet textures available in the facility. The in-service emphasized the following: Diet orders will be printed daily by the licensed nurse and will be made available as a reference at the nurses' station. Food brought in by family from outside sources must be consistent with the resident's prescribed diet; Food brought in by family from outside sources should be shown to the licensed nurse for evaluation if it matches the resident's prescribed diet. The licensed nurse must be notified if the resident is observed to be eating food that does not match the diet order or when the family is observed to have brought in food for the resident that is different from the diet order. The licensed nurse will check on residents who have food brought in by family every 2 hours and as needed; and, The licensed nurse will record both the evaluation of the food brought from outside and every two-hour visual checks in a log that would be submitted to the DON or designee for further review.
- Licensed nurses and CNAs were asked questions at the end of the in-service to evaluate their knowledge of the information provided in the in-service. In-services would be completed for all the active nursing staff by the Nurse Consultant. Staff who were currently on vacation or on leave will be provided the in-service upon their return to work.
- The Nurse Consultant checked competencies of RNs, LVNs and CNAs, as in identifying different diet textures by presenting them with different sample meal trays and asking them to correctly identify different diet textures and fluid consistencies. Competency evaluations would be performed by the Nurse Consultant and completed for all active nursing staff. Staff who were currently on vacation or on leave would have their competencies evaluated upon their return to work.
- The Nurse Consultant provided a one-to-one in-service with CNA 1 regarding the facility's policy on Food for Resident from Outside Sources, emphasizing the importance of reporting to the licensed nurse when the resident was observed to be eating food that was different from the diet order. At the end of the in-service, the CNA was asked questions to evaluate his knowledge about the information provided to him and was able to answer questions correctly.
- The Nurse Consultant provided an in-service to CNAs and RNAs regarding the importance of immediately reporting to the licensed nurse any observed changes in the resident's condition and acting upon any actions that do not match the facility's policy on Food for Resident from Outside Sources. The Nurse Consultant would complete the in-service for all the active CNAs and RNAs. Staff who were currently on vacation or on leave would be provided the in-service upon their return to work.
- The RD would review diet orders once a week to ensure diet orders were clear and correct. She would conduct rounds once a week to ensure that residents were provided the correct diet texture and fluid consistency. Findings would be reported to the Director of Nursing (DON) and Administrator weekly for follow-up.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to label and remove expired food from resident refrigerators. Two residents had personal refrigerators containing unlabeled, undated, or expired items, including yogurt, probiotic drinks, and candy brought in by family. The DON said CMAs checked temperatures while managers were supposed to check for expired food and labeling each morning, but specific room assignments were not identified and new management staff were still being trained.
Unlabeled food was found in a resident refrigerator located in the staff break room, including frozen dessert, strawberry ice cream, and a sealed cup of vanilla ice cream with no name or expiration date. Cook 1, the DS, LVN 3, and the DON all stated outside food should be labeled with the resident's name and date information, and that expired or unlabeled items should be discarded. The facility policy also required outside food to be labeled and unsafe or unlabeled items to be discarded.
Undated food items were found in two residents’ personal refrigerators, including cake, a sandwich, milk, and melting ice cream stored in the refrigerator area instead of the freezer area. Both residents had intact cognition and required setup or clean-up assistance with eating, and nursing staff stated the food should have been checked, labeled, and dated when refrigerator temperatures were monitored.
Unlabeled and improperly stored food brought in by family or visitors was found in a resident's refrigerator and freezer. An IP observed an unlabeled bag in the refrigerator and several unlabeled items in the freezer, and stated there was no way to identify who the food belonged to or when it should be discarded. The facility handout and P&P required outside food to be labeled with the resident's name and use-by date and stored separately from facility-prepared food.
Undated, unlabeled bean dip with visible fuzzy, slimy patches was found in a resident’s personal refrigerator. The resident had intact cognition and said he stored snacks there but had forgotten the bean dip. CNA and LVN staff confirmed the item was present, and the DON stated nursing staff were responsible for removing undated, unlabeled food items and helping families label and date food brought in.
No designated refrigerator was available for residents’ food brought in from outside sources. The DON, RD, ADM, and DS all confirmed the facility did not store outside food, with staff citing liability, monitoring, space, and added temperature-check steps; the DS also stated corporate stopped holding resident food after Covid-19, although the facility previously had a refrigerator for this purpose. Residents and a family member stated they wanted their outside food stored, and the facility policy required labeled storage for food left with residents while stating perishable foods could not be stored and had to be consumed within 2 hours.
Failure to Label and Remove Expired Food from Resident Refrigerators
Penalty
Summary
The facility failed to follow its food storage policy for resident refrigerators by not ensuring that foods brought in by family or other visitors were labeled, dated, and not expired. During observation, Resident #13’s personal refrigerator contained 3 small individual cups of yogurt with no expiration date and a plastic zip top bag of candy pieces that was not labeled or dated. Resident #13, who had diagnoses including vascular dementia without behavioral disturbance, type 2 diabetes mellitus with hyperglycemia, lack of coordination, and hyperkalemia, was alert and said her family had brought the items in, but she could not remember when. Resident #43’s personal refrigerator was also observed to contain 4 small probiotic drink bottles with no expiration date and 1 individual cup of yogurt that was expired. Resident #43 had diagnoses including systolic congestive heart failure, type 2 diabetes mellitus without complications, generalized muscle weakness, and essential hypertension, and her BIMS score was 13. Staff interviews showed CMA staff checked refrigerator temperatures, while managers were supposed to check for expired food, labeling, and cleanliness each morning; however, the DON and ADM could not identify which manager was assigned to check these two rooms, and the ADM stated new management staff were being trained and specific rooms had not been assigned.
Unlabeled food left in resident refrigerator
Penalty
Summary
The facility failed to ensure safe handling and storage of food brought into the facility for a resident by family or other visitors. During observation in the employee lounge where the resident refrigerator was located, one container of peanut butter and chocolate chip frozen dessert and one container of strawberry ice cream were found with no name or expiration date. A cup of vanilla ice cream sealed with plastic wrap was also observed with no name or expiration date. Cook 1 stated the resident refrigerator should not have items without a name and expiration date, and stated nursing staff were responsible for checking and cleaning out the refrigerator. The Dietary Supervisor stated nursing staff collected food brought in by family and placed it in the resident refrigerator, and that food brought in by family should be labeled with the resident's name, room number, and expiration date or date placed in the refrigerator. The Dietary Supervisor and DON both stated expired or non-labeled foods should be discarded. LVN 3 stated outside food should be labeled with the resident's name, room number, and date placed in the refrigerator, and that food in the resident refrigerator should have an expiration date. The facility policy required food brought in from outside sources to be labeled with the resident's name, date received, and food item description, and stated expired, spoiled, unlabeled, or unsafe food items shall be discarded.
Undated Food Items Stored Improperly in Resident Refrigerators
Penalty
Summary
The facility failed to follow its policy regarding the use and storage of foods brought to residents by family and other visitors for 2 of 28 residents reviewed. On 05/17/2026, Resident #11, a 63-year-old male with diagnoses including respiratory failure, COPD, and bronchitis, was observed with a personal refrigerator in his room containing one piece of cake, a sandwich, and one cup of milk, with no dates on the food. His quarterly MDS dated 05/11/2026 showed a BIMS score of 13 out of 15, indicating intact cognition, and he required setup or clean-up assistance with eating. His care plan identified a risk for malnutrition related to diabetes and included a regular diet with thin liquids. Also on 05/17/2026, Resident #43, a 73-year-old female with diagnoses including a left humerus fracture, conversion disorder, and hypertension, was observed with a small refrigerator in her room containing melting ice cream in the refrigerator area instead of the freezer area, with no date on it. Her admission MDS dated 4/30/2026 showed a BIMS score of 14 out of 15, indicating intact cognition, and she required setup or clean-up assistance with eating. Her care plan identified a potential nutritional problem related to weakness and included a regular diet with thin liquids. Interviews with nursing staff indicated the food items had no dates and that the nurse should have checked the food when checking refrigerator temperatures and labeled and dated the items.
Unlabeled and Improperly Stored Outside Food
Penalty
Summary
The facility failed to ensure that food brought into the facility from outside was labeled and stored appropriately for one sampled resident refrigerator, in accordance with the facility's policy and procedure titled Food Brought from Outside the Facility. During a concurrent observation and interview in the entero food supply room, an unlabeled white bag was found in the refrigerator for the resident's personally supplied food. The Infection Preventionist removed the bag and stated there was no label identifying who the item belonged to or dates identifying when to throw it away. During the same observation, three transparent bags with fruit, one plastic purple water bottle, one gallon container of Neopolitan ice cream, and one gallon container of rocky road ice cream were observed in the freezer for the resident's personally supplied food. The Infection Preventionist stated there was no label showing who the items in the resident's freezer belonged to. Review of the facility handout titled Food Brought from Outside the Facility indicated containers would be labeled with the resident's name and use-by date, and the policy stated food brought by family or visitors and left with the resident to consume later would be labeled and stored in a manner clearly distinguishable from facility-prepared food.
Undated, unlabeled food found in resident refrigerator
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of a resident’s food items in 1 of 5 reviewed residents’ refrigerators. Resident #39 had diagnoses including benign prostatic hyperplasia, bipolar disorder, and borderline personality disorder, and a BIMS score of 15 indicating intact cognition. On 5/05/2026, the resident’s personal refrigerator was observed to contain an unlabeled, undated bean dip container with unidentified fuzzy, slimy patches. During interview, Resident #39 stated he stored snacks in his personal refrigerator but had forgotten the bean dip was there. CNA B stated she was assigned to the resident and saw the undated, unlabeled bean dip container, but did not know who was responsible for checking the refrigerator for expired food. LVN A confirmed the container was in the resident’s refrigerator and stated nursing staff were responsible for removing undated and unlabeled food items, but she had not checked the refrigerator that day. The DON stated perishable food and drinks in residents’ personal refrigerators should be labeled and dated, and that nursing staff were responsible for removing undated, unlabeled food items and assisting families in labeling and dating food brought in. The facility policy, Food Brought in by Family / Visitors, stated nursing staff will discard perishable foods before the use by date.
No Designated Refrigerator for Residents’ Outside Food
Penalty
Summary
The facility failed to provide a safe storage refrigerator designated for residents’ food brought in from outside sources. During interviews, the DON stated there was no refrigerator for food brought in by families from outside the facility, and the RD stated the facility could not store outside food unless it was non-perishable. The RD further stated hot and cold foods could sit out for 2 hours and then had to be thrown out, and explained that the facility did not have a separate refrigerator because of concerns about liability, monitoring, and the work involved in labeling residents’ food. The facility policy titled, Food Brought by Family/Visitors, stated food left with the resident to consume later is to be labeled and stored so it is clearly distinguishable from facility-prepared food, while perishable foods cannot be stored in the facility and should be consumed within 2 hours. Resident 97 was admitted with acute kidney failure, had moderately impaired cognition, required supervision with eating, and was on a fortified regular texture diet. During interview, Resident 97 stated she would like to store outside food in the facility for a day or two and believed everyone would like their food stored as well. Resident 134 was admitted with hemiplegia, was cognitively intact, required setup or clean-up assistance with eating, and was on a regular diet. Resident 134 stated he would like to have a refrigerator to store food brought in from the outside. Resident 106 was re-admitted with severe protein-calorie malnutrition, was severely cognitively impaired, was independent with eating, and was on a fortified puree diet. The resident’s family member stated she wished to have food brought in from outside stored at the facility. The Administrator stated the facility told families that hot and cold foods had to be eaten within a certain time frame because the facility did not store residents’ food, and the Dietary Supervisor stated that after the Covid-19 pandemic corporate said the facility would no longer hold food for residents, although before Covid-19 the facility had a refrigerator designated for residents’ outside food.
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