Failure to Adhere to Resident's Dietary Needs Leads to Fatal Incident
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of a resident, leading to a serious incident. The resident, who had a mechanically altered diet due to dysphagia and other medical conditions, was given a peanut butter sandwich by a staff member, contrary to the dietary orders that specified no bread. This incident occurred during snack time when the staff member, unaware of the resident's specific dietary restrictions, provided the sandwich, which was not suitable for the resident's mechanical soft diet. The resident had a history of severe cognitive impairment, dysphagia, and other health issues that required a mechanically altered diet with close supervision. The resident's care plan and dietary orders clearly indicated the need for a mechanically soft diet with no bread, to prevent choking and aspiration risks. Despite these orders, the staff member provided a peanut butter sandwich, which was a dense and dry food item, unsuitable for the resident's dietary needs. The incident resulted in the resident experiencing distress and ultimately expiring. Interviews with staff revealed a lack of awareness and adherence to the resident's dietary orders, as well as inconsistencies in the communication and understanding of the resident's dietary needs. The staff member involved admitted to not knowing the specific diet the resident was on at the time of the incident, highlighting a critical gap in the facility's dietary management and staff training processes.
Removal Plan
- The regional nurse consultant, regional reimbursement consultant, the director of nursing, and the MDS audited all Matrix EHR orders to validate that they matched the RD Dining Meal ticket system and that they were on the Resident Profile so that the CNAs and other facility workers can identify the diet that the resident is on and any precautions that are in place. Any concerns or discrepancies were corrected immediately upon discovery. Snacks ordered for weight loss interventions were audited and all were correct.
- The director of nursing/designee in-serviced facility staff on where to find the diet information for a resident. Facility staff will receive the information before starting their next assigned shift. Agency staff will receive the information before starting their assigned shift.
- The CNA who fed the resident bread was individually re-educated by the administrator and the director of nursing regarding following the resident diet and where to find diet information.
- The regional nurse consultant in-serviced the administrator and the director of nursing on new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the Resident Profile. New admission orders will be reviewed in the Interdisciplinary Team Meeting (IDT) and corrections made when needed. The RD Dining Meal Ticket system will also be checked at that time to validate that everything matches. The MDS will then develop a care plan for any dietary needs identified per the regulation.
- The RD recommendations will be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders entered per the above processes. The Resident Profile and care plan will be updated at that time. Any concerns will be discussed in the weekly Quality of Care meeting.
- Speech therapy recommendations will be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders will be entered per the above processes. The Resident Profile and care plan will be updated at that time. Any concerns will be discussed in the weekly Quality of Care meeting.
- An Ad Hoc QAPI meeting was held with the facility medical director to discuss the deficiency and actions put in place by the facility.
- The administrator will monitor the new orders for diets from the RD or the Speech Therapist, weekly for one month and randomly thereafter by reviewing the facility activity report, actual food on meal trays, and documenting findings on a log created by the facility. Any concerns or trends will be brought to the monthly QAPI meeting for tracking and trending and new IDT recommendations.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, malnutrition, heart failure, and documented swallowing difficulties, who was on a mechanically altered diet with a physician order and care plan specifying a regular diet with ground meats, was served a whole sausage patty without gravy at breakfast instead of ground meat with pork gravy as indicated on the meal ticket. A CNA and the Dietary Manager both confirmed the sausage should have been ground before service, contrary to the facility’s diet orders policy that requires diet therapy to match each resident’s medical condition and needs.
Two residents on modified diets for dementia and chewing/swallowing concerns were given snacks that did not match their ordered textures. One resident on a pureed diet, ordered after staff observed food being held in the mouth and poor chewing, was repeatedly provided ham sandwiches, potato chips, and an ice cream cone. Another resident on a minced & moist Level 5 diet with cut‑up foods was served a peanut cluster and later offered a crunchy “bird’s nest” snack with chow mein noodles and candy. Staff interviews revealed that activities staff supplied their own snacks without verifying diet orders, that the ST had not been consulted for a swallow evaluation in at least one case, and that nursing and dietary staff expected physician diet orders to be followed.
Staff failed to follow the facility’s pureed diet policy when preparing lunch for two residents on a puree diet. A dietary aide pureed Salisbury steak for two residents but did not measure the final volume or use the Pureed Diet Portion Sizes/Scoops chart to determine the correct scoop size, instead assuming it would match the pureed cauliflower and using a blue #16 scoop (2.66 oz) for both items. For the cauliflower, the aide did measure the volume and identified that a #6 scoop (5.3 oz) was indicated, but still used the smaller scoop. After service, there were leftover portions of both pureed cauliflower and meat, indicating incorrect portioning. The RD confirmed staff are required to use the volume method and that the aide did not follow the policy steps for the pureed meat.
Surveyors found that pureed cabbage served to multiple residents on pureed or mechanical soft diets was prepared with all of the cooking liquid instead of draining excess water as required by the facility’s recipe, then held on a steam table until service. Despite adding thickener and reblending, the pureed cabbage remained runny, spread across the plate, and did not hold its shape when portioned, which the district manager acknowledged was an inappropriate consistency and not in accordance with the facility’s therapeutic diet procedures.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with dysphagia, oropharyngeal dysphagia, Alzheimer’s disease, and severe cognitive impairment had clear EMR orders and care plan directives for a mechanical soft diet with ground meat and specific food restrictions. Despite this, dietary staff served the resident a whole chicken strip instead of ground meat, contrary to both the physician’s orders and facility policies requiring meat on mechanical soft diets to be chopped, flaked, or ground. During the meal, the resident choked on the chicken, and staff in the dining room performed the Heimlich maneuver, dislodging the food. Staff interviews revealed that the facility had a diet-card and multi-step verification process for ensuring correct diet texture, but this process was not properly followed for the resident’s meal, leading to the choking incident that surveyors cited as Immediate Jeopardy.
Failure to Provide Prescribed Ground Meat for Mechanically Altered Diet
Penalty
Summary
The facility failed to ensure that a resident on a mechanically altered diet received food in the prescribed form. During a breakfast meal observation, a resident with severe cognitive impairment was seen sitting up in bed with a meal tray in front of her. The meal ticket indicated she was on a regular diet with ground meat and was to receive scrambled eggs, a ground meat sausage patty with pork gravy, toast, butter, and jelly. Instead, a whole, unground sausage patty without pork gravy was present on the tray. A CNA confirmed that the sausage patty should have been ground and served with pork gravy. Record review showed the resident had diagnoses including dementia, malnutrition, and heart failure. An Annual MDS assessment documented that she was severely cognitively impaired, had complaints of difficulty and pain with swallowing, and was on a mechanically altered diet. The care plan, current through the survey period, identified risk for unintentional weight loss and included an intervention for a regular diet with ground meats and monitoring of food and fluid intake. A current physician’s order also specified a regular diet with ground meats. The Dietary Manager stated that the sausage patty should have been ground before leaving the kitchen. The facility’s Diet Orders policy indicated that the RD or designee would evaluate diet therapy according to each resident’s individual medical condition, needs, desires, and rights.
Failure to Provide Ordered Diet Textures During Nursing and Activities Snacks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received food in the texture ordered to meet their individual needs. One resident with dementia and Alzheimer’s disease had a physician’s order for a pureed diet after nursing, the DON, and the nurse practitioner observed that she was not eating well on a regular diet, was cheeking food, holding it in her mouth, and not chewing. Despite this pureed diet order, multiple nursing progress notes documented that she was given ham sandwiches and potato chips on several nights, and an activities note documented that she ate an ice cream cone. Staff interviews confirmed that she was on a pureed diet because she would let food sit in her mouth and that chips and sandwiches are not part of a pureed diet. The speech therapist stated he had not been asked to evaluate her swallowing, that he normally would want to screen residents whose diets were downgraded, and that non‑pureed foods for someone who holds food in their mouth would be a choking concern. Another resident with dementia and a severe cognitive impairment, as evidenced by a BIMS score of 3, had a physician’s order for a regular diet with minced and moist (Level 5) texture and cut‑up foods due to loose teeth. Nonetheless, an activities progress note documented that she ate a peanut cluster during a cooking social, and the Activities Director later reported that she was also given a “bird’s nest” snack made of crunchy chow mein noodles with candy on top, which she did not eat. Nursing staff stated that this resident did not have the mental capacity to chew, required extensive cueing, and that they would be concerned about choking if she were served non‑minced and moist foods. The Dietary Manager reported that the Activities Department provided its own snacks and did not ensure residents received the correct diet textures, and the DON stated that staff were expected to follow physician orders for diet textures despite limited availability of the speech therapist.
Failure to Follow Puree Diet Portioning Procedure for Two Residents
Penalty
Summary
The deficiency involves failure to follow the facility’s pureed diet policy and procedure for determining appropriate portion sizes for two residents on a pureed diet. During a lunch meal observation, a dietary aide pureed Salisbury steak for two pureed-diet residents but did not measure the pureed meat in a volume measuring cup before service, contrary to policy. Instead, the aide transferred the pureed meat directly from the food processor to a serving dish on the steam table and selected a blue #16 scoop (2.66 oz) for serving, based on the assumption that the meat portion would be the same as the pureed cauliflower. The aide reported having placed two pieces of Salisbury steak into the food processor but did not calculate the final volume or determine the correct scoop size using the facility’s Pureed Diet Portion Sizes/Scoops chart. In contrast, the aide followed the required steps for the pureed cauliflower by pureeing it, transferring it to a measuring cup, obtaining the volume, and then using the chart to select the correct scoop size, which was identified as a #6 scoop (5.3 oz). Despite this, the aide used the same blue #16 scoop for both the cauliflower and the meat. After lunch service, the aide confirmed there was approximately half a serving of pureed cauliflower and about one full serving of pureed Salisbury steak left over, even though only two residents were on a pureed diet. The registered dietitian later confirmed that staff are expected to use the volume method and acknowledged that the aide did not measure the pureed meat and that there should not have been leftover pureed meat if the correct scoop size had been used. The facility’s written policy requires adding the correct number of servings to the processor, pureeing to proper consistency, measuring the final volume, using the chart to determine serving size, and labeling with serving size, steps that were not followed for the pureed meat.
Improper Preparation and Consistency of Pureed Cabbage
Penalty
Summary
The facility failed to ensure pureed foods were prepared in accordance with individual needs and facility recipes, specifically in the preparation of pureed cabbage served at one lunch meal to 22 residents on pureed or mechanical soft diets. During observation of the puree preparation, a staff member removed cooked cabbage from the oven, measured its temperature at 205.2°F, and portioned 33 four-ounce servings of cabbage along with all of the cooking liquid into a food processor. Over the course of the preparation, the staff member added four tablespoons of thickener and reblended the mixture multiple times before placing the pureed cabbage into a steamer for hot holding. The facility’s written recipe for braised cabbage directed that excess water be drained off before pureeing, but this step was not followed. Subsequent observations during trayline service showed that the pureed cabbage, held on the steam table, had a runny consistency that spread across the plate and did not hold its shape when scooped with a #8 scoop. Food temperatures taken before service showed the pureed cabbage at 181°F. The district manager confirmed that residents on pureed or mechanical soft diets received this pureed cabbage and acknowledged that the consistency observed on the plates was not appropriate. A test tray sampled later the same day showed the pureed cabbage remained runny and had broken down while on the steam table, losing some of its consistency. Review of the facility’s therapeutic diet policy indicated that diets are to be prepared according to the approved diet manual and individualized care plans, and review of the cabbage recipe confirmed that draining excess water was required but had not been done.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Follow Mechanical Soft Diet Orders Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with food in the physician-ordered mechanical soft, ground meat form. The resident had diagnoses of dysphagia, oropharyngeal phase dysphagia, and Alzheimer’s disease, with a BIMS score of four indicating severe cognitive impairment. Her MDS and CAAs documented that she coughed or choked during meals or when swallowing medications and that she required a mechanically altered diet. The care plan and EMR orders specified a regular diet with mechanical soft texture, ground meat with gravy or sauce (no dry meat), and multiple restrictions including no soft tortilla shells, no salad, no raw onions, no raw vegetables, and tortilla chips to be crushed or broken. An intervention also directed staff to cut up her food and remind her to take only one bite at a time. Despite these documented needs and orders, on the day of the incident the resident was served a whole chicken strip instead of ground meat. A nurse’s note recorded that the resident received a whole chicken strip for lunch and choked on a bite of chicken. Staff statements confirmed that dietary staff provided a whole chicken strip, and one dietary staff member stated he had chopped one up but then set it aside and gave her a whole chicken strip because he could not remember if they were supposed to be chopped for her. This action directly conflicted with the resident’s ordered mechanical soft diet with ground meat and the facility’s own policies requiring foods to be cut, chopped, or ground to meet individual needs and specifying that meat, fish, and poultry on mechanical soft diets should be chopped, flaked, or ground. When the resident began choking, another resident alerted staff in the dining room. Staff observed the resident choking, and a CNA and another staff member attempted and then performed the Heimlich maneuver, resulting in the resident expelling a chunk of food onto the floor and stating she felt better. A prior progress note also documented that the resident had experienced a possible choking episode in the dining room on an earlier date, during which she was observed coughing with blue lips, encouraged to cough up a moderate amount of mushy substance, and suctioned for a moderate amount of thick, clear mucus. The facility’s dietary and nursing staff interviews described an established process using diet cards and multiple verification steps to ensure correct diet texture and consistency, but staff acknowledged that this process was not thoroughly followed for this resident’s meal, resulting in her receiving a full chicken strip instead of the ordered mechanical soft, ground meat diet. This failure led to a choking episode that surveyors determined constituted Immediate Jeopardy.
Removal Plan
- Provide in-service education for dietary monitoring and ensuring proper diets are served to each resident for direct-care staff and kitchen staff
- Provide 1:1 education with the cook and dietary aide
- Implement disciplinary action for the cook and dietary aide
- Provide 1:1 in-service education with all staff who serve in the dining room
- Revise the dining room monitoring schedule to include manager coverage for all meals
- Verify all at-risk residents to ensure diets match their diet cards
- Provide RELIAS educational training for the cook
- Hold a QAPI meeting with the Director of Nursing, Administrator, and Medical Director
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