Failure to Implement Diet Order Leads to Resident's Death
Summary
The facility staff failed to implement a physician's order for a resident's downgraded diet to mechanical soft, which resulted in the resident experiencing a second choking episode. The resident, who had diagnoses including Parkinson's disease, dementia, dysphagia, congestive heart failure, and muscle weakness, was initially ordered to receive a mechanical soft diet after a choking incident. However, this order was not entered into the resident's medical record, and the resident continued to receive regular food, leading to another choking episode. The nurse practitioner had specifically instructed the nursing staff to provide the resident with a mechanical soft diet and 1:1 supervision during meals until a speech therapy evaluation could be conducted. Despite these instructions, the nurse on duty did not enter the order into the medical record, nor did they communicate the new dietary requirements during the shift-to-shift report. As a result, the resident was served regular food, which led to choking on sausage that was not ground up. The failure to implement the physician's order and communicate the necessary dietary changes resulted in the resident being hospitalized and subsequently passing away from complications of aspiration pneumonia and choking on food. The facility's policies on verbal orders and diet consistency changes were not followed, contributing to the immediate jeopardy situation identified by the surveyors.
Removal Plan
- Education by Director of Nursing with all nursing staff on the facility's Diet Consistency/Texture Change Protocol policy and physician orders.
- Review of all residents at risk for aspiration, choking, and/or noted with swallowing difficulty.
- Physician orders audited by Director of Nursing or Assistant Director of Nursing or designee.
- Shift to shift report audited by Director of Nursing and Assistant Director of Nursing to ensure completion.
- Facility DON and Administrator reviewed policies and procedures on shift-to-shift report and physician orders with the medical director.
- Quality Assurance Audit tool used for monitoring implementation of physician orders, with audits done for 5 residents.
- Audit of shift-to-shift report completed for 10 residents.
- Results of QA Audits reviewed by the Facility QAPI team to determine any necessary changes.
- Emergency QA meeting held by the Administrator with the Interdisciplinary Care Team and Medical Director to discuss residents at risk for choking, diet downgrades, and in-services for physician orders and shift-to-shift report.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, multiple vitamin deficiencies, and documented dental issues had a physician order for a high‑protein supplement TID with meals and a recorded dislike of chicken. During a lunch meal, the resident was served chicken cordon bleu and did not receive the ordered high‑protein milkshake, even though both the supplement order and the chicken dislike were clearly printed on the diet ticket. The resident reported inconsistent receipt of the milkshakes and reiterated his dislike of chicken, while a CNA, the Dietary Manager, and the DON each confirmed that the meal and supplement provided did not match the documented physician orders and stated food preference.
Residents with physician-ordered consistent carbohydrate diets for diabetes were not provided foods consistent with their prescribed therapeutic diets. Facility policy and diet extension sheets required that residents on a consistent carbohydrate diet receive diet angel food cake instead of regular angel food cake, but during a lunch meal service, residents on these diets were observed receiving the same regular angel food cake as those on liberalized diets. The Dietary Manager confirmed that no differentiation was made between diet orders, and product labeling showed the cake contained significant sugar and carbohydrates, contrary to the intended diet extension.
A resident with a physician-ordered regular diet with mechanical soft texture and thin liquids, and documented dysphagia precautions with mechanical soft/chopped textures, was observed at lunch feeding independently with no staff present while their tray contained potato chips and saltine crackers. Signage above the bed indicated a mechanical soft, chopped meats, thin liquids diet, and the meal ticket read “Regular-DYS ADV,” indicating avoidance of hard, sticky, or crunchy foods. A CNA, UM, Speech Pathologist, and CDM all confirmed that chips and crackers are not appropriate for a mechanical soft diet and should not have been placed on the tray, indicating the ordered therapeutic diet was not followed.
Two residents did not receive diets as ordered by their physicians. One resident with esophageal cancer, dysphagia, and dementia had an NPO order but was repeatedly given or attempted to be given meal trays, as confirmed by grievances from the family and by facility staff. Another resident with ESRD on dialysis, diabetes with CKD, chronic hepatitis, and dementia had a 1000 ml/24 hr fluid restriction ordered, yet was observed with multiple cans of ginger ale and hot chocolate on the lunch tray, while CNAs stated the resident could have what he wanted with meals. There was no documentation of physician or family notification about this resident’s noncompliance with fluid restrictions, despite facility staff acknowledging that diets and restrictions should follow physician orders.
Two residents with impaired cognition and swallowing needs did not receive their prescribed therapeutic diets and thickened liquids. One resident ordered a puree diet with thickened liquids and extra gravy at all meals was repeatedly fed without the required extra gravy and was given unthickened water at the bedside. Another resident ordered a dysphagia advanced diet with nectar thickened liquids, and allowed only regular texture foods for pleasure, was repeatedly given an unthickened dark soda. Staff, including CNAs, an RN, and a speech therapist, confirmed that the liquids were not thickened and that the orders did not permit regular liquids for pleasure, contrary to the facility’s therapeutic diet policy.
Surveyors found that staff failed to follow ordered therapeutic diets for three residents with dysphagia and high aspiration risk. A resident on strict NPO status after a stroke was mistakenly brought to the dining room and served a regular sandwich and juice by a dining assistant who did not verify her diet order, leading to a hypoxic episode and ED transfer. Another resident ordered a Level 4 pureed diet with thin liquids, with a recent history of choking and an EGD for food bolus removal, was observed eating a hotdish with chunks of turkey intended for regular or minced and moist diets, while dining staff admitted they did not consistently use iPads or diet slips to confirm diets. A third resident on a Level 4 pureed diet with Level 2 mildly thick liquids, with prior documented choking and pocketing episodes and care plan restrictions on snacks, was observed unsupervised in the hallway eating Oreo cookies, despite no consent for a liberalized diet and family instructions that he should not have such items.
Failure to Provide Ordered High-Protein Supplement and Honor Food Dislike
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered high‑protein supplement and to honor a documented food dislike for a resident with multiple nutritional deficiencies and moderate cognitive impairment. The resident’s diagnoses include unspecified dementia with moderate cognitive impairment, vitamin D, E, and ascorbic acid deficiencies, and a disorder of teeth and supporting structures. A dietary physician order dated February 4, 2026, specifies that the resident is to receive a regular high‑protein supplement three times daily with meals at 7:30 a.m., 12:00 p.m., and 5:30 p.m. The same physician order/meal ticket also documents that the resident dislikes chicken. On observation at a lunch meal, the resident was served chicken cordon bleu as the entrée and did not receive the ordered high‑protein milkshake supplement, despite both the supplement and the chicken dislike being clearly documented on the physician order/meal ticket. The resident later stated that he does not like chicken, but ate the entrée because the ham inside made it more tolerable, and reported that he enjoys the high‑protein milkshakes but does not receive them consistently at every meal as ordered. A CNA confirmed that the resident did not receive the high‑protein milkshake and was given chicken in error, acknowledging that both the supplement and the chicken dislike were on the ticket. The Dietary Manager confirmed that chicken was listed as a dislike and that the high‑protein supplement was ordered three times daily, and acknowledged that the kitchen staff missed adding the supplement. The DON also confirmed that the physician order/dietary ticket documented the chicken dislike and the high‑protein milkshake order.
Failure to Follow Consistent Carbohydrate Diet Extensions for Diabetic Residents
Penalty
Summary
The facility failed to ensure that residents on physician-ordered consistent carbohydrate diets received foods in the appropriate form and nutritive content as specified by the therapeutic diet extensions. Facility policy titled "Consistency Alterations and Therapeutic Menus" stated that the regular/liberalized menu would be extended for therapeutic diets, including consistent carbohydrate diets, to provide diets as ordered by the physician/APP. The facility’s diet extension sheet for a specific lunch meal indicated that residents on a regular/liberalized diet should receive a slice of angel food cake, while residents on a consistent carbohydrate diet should receive a slice of diet angel food cake. However, during observation of the tray line meal service, multiple residents on consistent carbohydrate diets for diabetes were served regular angel food cake instead of the diet version. Review of physician orders showed that six observed residents, as well as numerous additional residents, were ordered consistent carbohydrate diets for diabetes. Despite these orders and the diet extension sheet, the Dietary Manager confirmed that the same angel food cake was served across all diet orders, without differentiation for the consistent carbohydrate diet. Review of the nutrition facts and ingredients label for the angel food cake served revealed it contained 28 grams of total carbohydrates and 20 grams of sugar, with sugar listed as the primary ingredient and no sugar substitutes present. The Nursing Home Administrator stated that he would expect therapeutic diets to be provided as ordered and for extension sheets to be followed for therapeutic diet alterations.
Failure to Follow Ordered Mechanical Soft Therapeutic Diet
Penalty
Summary
The facility failed to provide an ordered therapeutic diet to a resident who had a physician order dated 2/1/26 for a regular diet with mechanical soft texture and thin consistency, and speech therapy documentation for mechanical soft/chopped textures with dysphagia precautions. On the morning of 2/19/26, signage above the resident’s bed indicated a mechanical soft diet with chopped meats and thin liquids. At lunchtime the same day, the resident was observed feeding himself without staff present, and his meal tray contained approximately seven potato chips and two saltine crackers. The meal ticket on the tray read “Regular-DYS ADV,” indicating a regular diet avoiding hard, sticky, or crunchy foods, with foods to be bite-sized. During subsequent interviews, a CNA, the Unit Manager, the Speech Pathologist, and the Certified Dietary Manager each stated that chips and crackers are not appropriate for a mechanical soft texture diet and should not have been on the tray. The Certified Dietary Manager stated that dietary staff are expected to read each meal ticket and place food on the tray according to the therapeutic diet, and acknowledged that the chips and crackers should not have been included. The Regional Nurse Consultant, acting as DON, and the Administrator both stated their expectations that staff follow therapeutic diets according to meal tickets and physician orders, confirming that the observed tray contents did not align with the ordered mechanical soft diet and dysphagia-related precautions documented for the resident.
Failure to Follow Physician-Ordered NPO and Fluid-Restricted Diets
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets for two residents. One resident had diagnoses including malignant neoplasm of the esophagus, dysphagia, and dementia, with a BIMS score of 2 indicating significant cognitive impairment, and a physician order dated 12/9/25 for nothing by mouth (NPO). Despite this order, the resident’s representative reported three occasions when staff attempted to give the resident food or fluids, and the grievance log documented that the family filed grievances in December 2025 and January 2026 after the resident received meal trays on two separate occasions. The Social Service Director confirmed that the resident had received trays on both occasions, contrary to the NPO order. The second resident had diagnoses including ESRD with dependence on dialysis, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic hepatitis, and dementia, with a BIMS score of 5 indicating significant cognitive impairment, and was on a therapeutic diet with a physician order for a 1000 ml fluid restriction per 24 hours, divided between nursing and dietary. During observation, this resident was served a lunch tray with multiple cans of ginger ale and an additional cup of hot chocolate placed on the tray by a CNA, who stated the resident could have what he wanted and that he got enough, when asked about fluid restrictions. Another CNA stated that the computer system and tray ticket identify diet and fluid restrictions and that the resident could have what he liked with meals, just nothing in between. Record review showed no documentation of physician or family notification regarding the resident’s noncompliance with fluid restrictions. The RD and DON both stated that residents should receive diets as ordered by the physician and that notification should occur when there is noncompliance, but the RD acknowledged knowing of the resident’s noncompliance without having spoken with the dialysis center, physician, or family.
Failure to Provide Physician-Ordered Therapeutic Diets and Thickened Liquids
Penalty
Summary
Surveyors identified that the facility failed to ensure residents received their physician-ordered therapeutic diets. One resident with impaired cognition, few teeth, and a need for maximum assistance with feeding was ordered a regular puree diet with thickened liquids and extra gravy with all meals. Review of the resident’s meal ticket confirmed the extra gravy requirement. On multiple observed meal times, CNAs were feeding this resident without any extra gravy on or near the tray, and a bedside water pitcher contained liquids that were not nectar thickened as ordered. Staff verified that the extra gravy was not provided and that the water in the pitcher was not thickened, despite acknowledging that the resident sometimes needed additional gravy to ensure a smooth swallow. Another resident with diagnoses including hemiplegia, convulsions, cerebral infarction, dementia, and aphasia, and who was totally dependent on staff for feeding, had a physician order for a regular dysphagia advanced diet with nectar thickened liquids, with permission for regular texture foods for pleasure only. During observations, this resident was repeatedly provided a dark soda poured into a cup with a straw that was not thickened. A CNA confirmed the liquid was not thickened. Later, an RN and a speech therapist both verified that the physician’s order allowed regular texture foods for pleasure but did not include regular consistency liquids for pleasure. The facility’s own therapeutic diet policy stated that therapeutic diets are ordered by the physician to increase nutrients or provide foods residents are able to eat, yet the ordered diet consistencies were not followed for these residents.
Failure to Follow Therapeutic Diet Orders for Residents With Dysphagia and Aspiration Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure that therapeutic and modified diets were implemented and served in accordance with physician orders for three residents with dysphagia and high aspiration risk. One resident with dementia, dysphagia, aphasia, and a strict NPO order following a stroke was brought to the dining room after a therapy session, even though she did not normally dine there. The dining assistant, who had not used the available tablet to verify diet orders and believed the resident was someone else, served her a regular textured meal consisting of a ham or turkey sandwich with cheese and juice. The resident’s significant other observed her eating a sandwich and salad, and a staff member then stated she was not supposed to have food. The RN assessed the resident, found her SpO2 at 71%, and she was sent to the ED, where documentation indicated a transient hypoxic episode after being given lunch despite strict NPO status, with concern for an aspiration event. Another resident with multiple sclerosis, mild cognitive impairment, and dysphagia had a physician order for a Level 4 pureed texture diet with thin liquids. Her care plan identified a regular diet with pureed meats and directed staff to serve the diet as ordered. She had a recent history of choking and regurgitation episodes, including an event where she was spitting up food, had wheezing in the lower lung lobes, and required an ED visit with EGD and extraction of a food bolus. Despite this history and the ordered pureed diet, surveyors observed her in the dining room eating a hotdish made from stuffing with chunks of turkey, which dining staff identified as appropriate for a regular or minced and moist diet, not a pureed diet. At the time of observation, dining assistants acknowledged that diet information was available on iPads and diet slips but admitted they sometimes did not use them, and no such tools were in use until prompted by the surveyor. A third resident with dementia, expressive aphasia, and dysphagia had physician orders and a care plan for a Level 4 pureed texture diet with Level 2 mildly thick liquids. The care plan also documented that his family member could provide thin liquids and different textures only when present and that snacks left by the family for use in the resident’s absence were to be compatible with his modified diet. Progress notes documented prior concerns about pocketing food, a choking episode in the dining room where he was not breathing and had turned purple, and subsequent changes to a pureed diet and restrictions on snacks in his room. Despite these orders and documented risks, surveyors observed him independently propelling himself in his wheelchair near the dining room while eating Oreo cookies without staff supervision. The DON later confirmed there was no signed consent for a liberalized diet and that the family member did not want him to have Oreo cookies, and the facility’s own therapeutic diet policy required that snacks be compatible with the therapeutic diet.
Removal Plan
- Review the facility process for ensuring the correct resident receives the correct diet as prescribed by the provider.
- Review and revise care plans for accuracy.
- Educate all staff with competency on resident care plan revisions, the facility procedure for implementing physician-ordered diets, diet textures, and protections from negative outcomes.
- Implement meal tray audits.
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