Resident Choking Incident Due to Incorrect Meal Texture
Summary
The facility failed to provide food prepared in the correct form to meet the needs of a resident, leading to a choking incident. The resident, a female with a history of Alzheimer's Disease, aphasia, dysphagia, and other conditions, was supposed to receive a pureed diet with nectar thickened liquids. However, on the day of the incident, she was mistakenly given a mechanical soft diet, which was not in accordance with her physician's orders. This error occurred when an agency CNA, unfamiliar with the residents and the facility, fed the resident the wrong meal tray. The incident unfolded when the agency CNA, who had not received proper orientation for the hall she was assigned to, mistakenly fed the resident a meal intended for her roommate. The error was discovered when another CNA noticed the resident showing signs of distress, such as vomiting and a flushed face. The charge nurse was alerted, and immediate action was taken to address the choking, including performing the Heimlich maneuver and calling for medical assistance. The resident's oxygen levels were monitored, and a chest x-ray was ordered, which later showed no signs of aspiration. Interviews with staff revealed that the agency CNA was not familiar with the facility's residents and had not been oriented to the specific hall where the incident occurred. The facility's policy required licensed nursing staff to check meal trays for accuracy, but this procedure was not effectively followed, leading to the mix-up. The incident highlighted a breakdown in communication and procedural adherence, particularly concerning the distribution of meals and the orientation of agency staff.
Removal Plan
- Resident #1 will receive the appropriate physician ordered diet for all meals.
- Resident #1 has had a chest x-ray. The results reveal no negative outcome to her lungs.
- Resident #1's physician who is also the medical director has been notified both of the incident and the IJ status at the facility.
- A facility audit took place to ensure that all residents requiring modified texture diets for meals will receive their meals in the appropriate texture.
- DON and the dietary consultant audited all residents who require their diet to be served in an altered texture for meals to ensure that their meal tickets reflect the residents individual needs regarding texture with food in accordance with physician's diet orders.
- The dietary department designee will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate.
- The nurse in the dining room will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate.
- The nurse on the hall will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate.
- The DON will monitor meals to ensure staff compliance with ensuring that all meals/trays have the appropriate texture that matches the meal ticket and the physician ordered diet.
- Residents meal texture statuses will be audited upon admission, change of condition, appropriate MDS cycles and or anytime necessary.
- All trays will be compared to the actual plated meal for the resident by a licensed staff member prior to being served to the resident. The printed meal ticket will be compared to the tray/plate for accuracy.
- The Assistant Director of Nursing provided education to all staff regarding residents requiring specially textured meals to ensure those residents will receive the appropriately textured meal at all times.
- Licensed staff will be assigned by the DON to ensure that all trays/plates are correct prior to being served to the residents. Diet orders will match correctly to what is being served to the residents.
- The Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding residents requiring specially textured diets for meals.
- The regional clinical consultant will be responsible for ensuring that staff receive the inservice/training regarding residents requiring specially textured food for meals.
- The residents dietary food texture status will be communicated to facility staff directly by the DON and ADON. This process will be accomplished through photo copy and or written communication.
- The DON or their designee will be responsible for ensuring that the residents who require specially textured diets receive their food with the appropriate texture according to the physician's ordered diet.
- During the daily stand up process all recommendations and orders will be audited by the clinical team in consultation with the dietary supervisor to ensure compliance and follow up for all residents with orders and recommendations.
- The clinical consultant will review orders and recommendations as a tool for oversight to ensure compliance.
- Staff have been re-educated to identify the resident's diet by room number and bed designation of A or B.
- 100% Staff education compliance for those who may serve food to a resident will be completed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to follow neutropenic meal restrictions for a resident receiving chemo. The resident had an order for reverse isolation, but the meal ticket did not identify that fresh fruits and vegetables were prohibited, and meal records showed the resident was served multiple fresh fruits and vegetables. The Dietary Manager stated she was not alerted to the resident’s neutropenic isolation status.
A resident with COPD, schizoaffective disorder, anorexia nervosa, anxiety, and HTN was ordered a regular diet with mechanical soft texture and thin liquids, but was served a whole cube steak instead of the required ground texture. Staff confirmed the resident was on a mechanical soft diet, and the DM verified the meat should have been ground per the ordered diet and the facility's tray identification process.
A resident with dysphagia and cognitive impairment was on a mechanical soft diet when she choked during breakfast and the LPN obtained an order to downgrade her to puree. The next morning, the resident was still served a mechanical soft tray with regular pancakes instead of the ordered puree diet, and she choked again, required CPR, was transported to the hospital, and later died. Staff reported the kitchen had not received a written diet change slip, and the facility had no policy guiding diet order changes.
Pureed foods were not prepared in the proper form for two residents with dysphagia who were on therapeutic diets. Kitchen staff made pureed potatoes, cauliflower, and strawberry crisp using scoops, water, milk, butter, and thickener, but did not perform IDDSI testing and relied on visual judgment for consistency. The RD expected staff to follow IDDSI and recipe directions, but the observed foods appeared thin and inconsistent with the required puree texture.
A resident with dementia and severe cognitive impairment was ordered a mechanical soft diet with nectar-thick liquids, but staff repeatedly provided regular thin liquids instead. Surveyors observed thin juice and water in front of the resident during meals, and staff confirmed the liquids were not nectar thick even though they knew the resident was supposed to receive nectar-thick fluids.
Pureed Foods Served in Improper Consistency: A DM prepared pureed breakfast and lunch items that were observed to contain chunks and a soup-like consistency rather than holding form. The ADM agreed the sausage with gravy and mixed vegetables were not the correct puree consistency, and the DM stated pureed food should be smooth and able to hold form.
Failure to Follow Neutropenic Meal Restrictions
Penalty
Summary
The facility failed to provide meals consistent with neutropenic precautions for one resident, R58, who had been admitted on 04/05/25 and had a physician order dated 01/16/25 for reverse (neutropenic) isolation after receiving chemotherapy. Review of the resident’s meal ticket did not indicate that fresh fruit and vegetables were to be withheld. Review of the facility’s meal records showed that R58 was served multiple fresh fruits and vegetables during the month, including broccoli salad, coleslaw, watermelon, sliced apples, tomato wedges, fresh fruit, creamy cucumber salad, sliced orange, grapes, cucumber/tomato salad, lettuce/tomato/onion, and cucumber salad. During interview on 05/28/26 at 1:38 PM, the Dietary Manager stated she was not alerted that R58 was on neutropenic isolation and therefore could not receive fresh fruit and vegetables. The facility policy titled Nutritional Management stated that the facility provides care and services to each resident to ensure acceptable nutritional status and that interventions will be individualized to address the specific needs of the resident.
Mechanical Soft Diet Not Provided as Ordered
Penalty
Summary
The facility failed to ensure a resident ordered a regular diet with mechanical soft texture and thin liquids received food prepared in the correct form. Resident #38 was admitted with diagnoses including COPD, schizoaffective disorder, anorexia nervosa, anxiety, and hypertension, and the admission MDS indicated intact cognition. The care plan identified the resident as at risk for altered nutritional status due to significant weight loss and included an intervention to provide meals, snacks, and fluids based on food preferences and physician orders. A physician order specified a regular diet with mechanical soft texture and thin liquid consistency. The facility menu for the day indicated cube steak for a mechanical soft diet should be ground and served with gravy, and the resident's meal ticket reflected a mechanical soft diet with an added grilled cheese at each meal. During lunch observation, the resident received a tray that included a whole cube steak rather than a ground texture. A CNA verified the resident was on a mechanical soft diet and confirmed the cube steak was not appropriate, and the Dietary Manager verified the cube steak should have been ground and not served whole. The facility policy stated mechanically altered diets are therapeutic diets and that the food service manager would use a tray identification system to ensure each resident received the ordered diet.
Failure to Follow Ordered Diet After Choking Incident
Penalty
Summary
The facility failed to provide a resident with the physician-prescribed diet, failed to have a policy in place regarding changes in dietary orders, and failed to implement a physician diet order change. The resident had diagnoses including metabolic encephalopathy, osteoarthritis, and dysphagia, and the facility assessment showed moderate cognitive impairment and a need for set-up assistance with meals. The resident was initially on a mechanical soft diet. After the resident was observed coughing and gagging while eating breakfast, the nurse performed the Heimlich maneuver and food was expelled. The on-call provider was contacted and ordered the diet downgraded to puree. A physician order for a pureed texture diet was entered that same day. However, the next morning the resident was served a mechanical soft breakfast rather than the ordered puree diet. Staff reported that the breakfast tray and diet slip still reflected mechanical soft, and the kitchen staff stated they had not received a written diet change slip showing the downgrade. During the second choking event, staff observed the resident coughing while eating breakfast in bed. Abdominal thrusts were attempted, a mouth sweep was performed, 911 was called, CPR was initiated when the pulse could not be obtained, and the resident was transported by EMS to the hospital. The emergency room record states large amounts of pancakes were found in the airway, intubation could not be completed in the field, and the resident died at 8:30 AM. The report states the Immediate Jeopardy began when the diet was changed to puree but the resident was still served mechanical soft food the next morning.
Pureed Foods Not Prepared to Required Texture Standards
Penalty
Summary
The facility failed to ensure pureed food was prepared in the proper form to meet individual resident needs for two sampled residents, both of whom had physician-prescribed therapeutic diets and diagnoses of dysphagia. Resident 4 had dysphagia, unspecified, and Resident 26 had dysphagia, oropharyngeal phase. On the lunch meal tray, both residents were served pureed foods that were prepared in a manner that did not match the expected IDDSI level 4 texture standards described in the facility documents. During kitchen observations, staff prepared pureed potatoes, pureed cauliflower, and pureed strawberry crisp using scoops, butter, hot water, milk, and thickener, but did not test the foods for the proper consistency. The pureed potatoes had flecks of skin and appeared very thin and watery. The pureed cauliflower also appeared thin. The strawberry crisp puree was prepared by eyeing the milk amount and blending without measuring the liquid, and staff stated they were looking for pudding consistency but did not test it. The Certified Dietary Manager later measured the strawberry crisp puree and found the amount in the cups was about one ounce short of filling a #8 scoop, prompting more puree to be made. Staff interviews and facility records showed that the Registered Dietitian expected staff to test pureed foods according to IDDSI and to use the spoon test after preparation. The recipes for the pureed potatoes, cauliflower, and strawberry peach crisp also directed staff to perform IDDSI testing to ensure texture standards were met. Facility in-services on IDDSI and pureed diets were documented, but no competency evaluation was provided for the staff involved in the preparation observed by surveyors.
Failure to Provide Ordered Nectar-Thick Liquids
Penalty
Summary
The facility failed to ensure a cognitively impaired resident with dementia and severe cognitive impairment received liquids in the prescribed nectar-thick consistency. The resident’s physician orders documented a regular mechanical soft diet with nectar consistency liquids, but the care plan lacked documentation of the nectar-thick liquid order. The dietary note stated nursing reported the resident was having trouble swallowing liquids and wanted slightly thickened liquids, and the facility noted that PointClickCare only had nectar thick liquids available as a diet option. During dining room observations, the resident was seen with regular thin liquids in front of her, including apple juice, orange juice, and water. On one occasion, the resident drank a full glass of orange juice and about 100 ml of apple juice before a CNA confirmed the juices were not nectar thick and stated she did not know who gave them to the resident. On another occasion, a CMA observed regular thin water in front of the resident and pushed it away, while dietary staff stated the resident was on nectar thick liquids and that the correct fluids should have been passed. Staff also reported the resident usually liked coffee and that her coffee was nectar thick when prepared by staff.
Pureed Foods Served in Improper Consistency
Penalty
Summary
The facility failed to ensure that pureed foods were prepared in a form designed to meet individual needs for 2 observed meals, breakfast and lunch. During the breakfast observation on 05/20/26 at 7:40 AM, the DM prepared pureed eggs, cream of wheat, and pureed sausage with gravy and provided a sample tray. When the surveyor tasted the pureed sausage with gravy, it contained small chunks of meat and was in a soup-like form, meaning it did not hold shape. During an interview at 7:58 AM, the ADM agreed that the sausage and gravy was not the correct consistency for puree form. During the lunch observation on 05/20/26 at 12:00 PM, the DM prepared pureed chicken, mashed potatoes, bread, and mixed vegetables and provided a sample tray. When the surveyors tasted the pureed mixed vegetables, they found small chunks and a soup-like form, meaning it did not hold shape. During an interview at 12:10 PM, the ADM agreed that the mixed vegetables were not the correct consistency for puree form. On 05/21/26, the DM stated she had been trained on puree form and to mix it so there were no chunks of food, and that pureed food should be smooth and able to hold form. The ADM stated she expected pureed foods to be safe and proper in consistency every time they were sent to residents and did not know why the foods were sent out when not in proper form.
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