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 CHF, COPD, and a thoracic vertebra fracture had an MD order for an 1800 ml/day fluid restriction and a CCHO/NS diet, but the meal ticket did not reflect the fluid limit. During meal service, the resident was served iced tea and chocolate milk by a dietary aide who said she was unaware of the restriction, and the RD stated she believed the restriction was a family preference.
A resident with cerebral infarction and HTN had a physician order for a low sodium diet, but was served ham at breakfast instead of the ordered scrambled eggs. The nurse aide confirmed the resident received ham, and the dietary manager said the tray line diet call-out was mistaken. The DON agreed residents should receive the diet prescribed by the physician.
Pureed Diet Served With Crusted Edges: A resident with chronic respiratory failure, tracheostomy status, ventilator dependence, and swallowing difficulty was ordered a pureed diet with honey thick liquids. During observation, the resident’s tray included pureed chicken with crusted edges, and RN, LC, DFN, and DON all stated the crusted edges were not acceptable because they could pose a choking hazard. The facility’s diet guideline required pureed foods to be smooth, lump free, and easy to swallow.
Therapeutic Diet Order Not Followed: A resident with COPD and Type 2 DM had a physician-ordered CCHO, NAS, minced and moist diet with thin liquids, but the dietary slip listed large portions. Staff interviews showed the large portions instruction was carried over from a prior admission and did not match the current MD order. The Dietary Supervisor stated the slip should have been verified before printing, and an RN stated only the physician can determine which diet orders continue or stop after readmission.
Fortified Foods Not Provided as Ordered: A resident with malnutrition and weight loss had a physician order for fortified foods at all meals, but meal service observations showed no fortified foods were prepared or served. Staff stated they were unaware of any residents needing fortified foods, and the RD was not aware of the order.
Failure to provide ordered double portions for a resident. The resident had a physician order for double portions, but staff did not deliver them as ordered, and an observed lunch tray did not include the extra portions. The RD confirmed the order and stated staff are typically told to give two trays when double portions are ordered. The resident had heart failure and a BIMS score of 10, indicating moderate cognitive impairment.
Fluid Restriction Not Reflected on Meal Ticket
Penalty
Summary
The facility failed to ensure diet orders, including a fluid restriction, were provided per physician orders for one resident. The resident was admitted with diagnoses including congestive heart failure, a thoracic vertebra fracture, and chronic obstructive pulmonary disease. Nursing documentation showed the physician was notified of family concerns and requests, and orders were added for a daily 1800 fluid restriction, daily weights, and a diet change from NAS to a carbohydrate-controlled diet. The resident’s diet order later reflected a CCHO/No Salt Packet diet with regular texture, regular fluid consistency, and an 1800 ml per 24-hour fluid restriction, with 360 ml per meal. During noon meal observation, the resident was seen with a glass of iced tea, then a glass of chocolate milk, and later two empty glasses were observed in front of him. The Dietary Manager and RD confirmed the meal ticket from the kitchen did not reflect the ordered fluid restriction, and the RD stated she believed the fluid restriction was a family preference. A Dietary Aide confirmed she served the resident both drinks and stated she was unaware of the fluid restriction; she identified the glasses as 240 ml each. Review of the meal ticket for that meal showed a CCHO/NS diet with no salt packets and regular texture and fluid consistency, without the fluid restriction reflected.
Therapeutic Diet Not Followed for Resident on Low Sodium Diet
Penalty
Summary
The facility failed to ensure that a resident received the therapeutic diet ordered by the attending physician. Resident 1 had diagnoses including cerebral infarction and hypertension, and the current physician order specified a low sodium diet, regular texture, regular/thin consistency, 2 gram sodium related to essential hypertension. Facility dietary instructions stated that residents on a low sodium diet should receive scrambled eggs instead of ham. During breakfast, Resident 1 was served ham rather than scrambled eggs and stated that he received ham and no scrambled eggs. He also reported asking where the scrambled eggs were and being told there were no scrambled eggs on Mondays. A nurse aide confirmed that Resident 1 received ham and said she did not know he should not have received it. The dietary manager reviewed the error and stated that the person calling out diets during tray line meal preparation made the mistake. The DON agreed that residents should receive the diet prescribed by the physician.
Pureed Diet Served With Crusted Edges
Penalty
Summary
Resident 18 was admitted with chronic respiratory failure, tracheostomy status, and ventilator dependence. The resident’s physician orders dated 9/3/2025 specified a pureed diet with honey thick liquids. The resident’s MDS dated 4/30/2026 indicated moderate cognitive impairment, dependence for eating and multiple activities of daily living, difficulty swallowing, tracheostomy care needs, and use of a therapeutic diet. The care plan identified an alteration in nutrition related to swallowing problems and directed staff to provide the diet as ordered by the physician and assess diet texture and tolerance. During a concurrent observation and interview on 7/14/2026 at 12:45 PM, Resident 18’s meal tray contained pureed chicken with crusted edges, pureed broccoli, and honey thick milk. RN 1 stated the crusted edges on the pureed chicken were hard and could pose a choking hazard for the resident. In later interviews, the LC, DFN, and DON each stated that crusted edges on a pureed diet were not acceptable because they present a choking hazard. The facility’s Diet Order Guideline stated that pureed foods should be easy to swallow, smooth, lump free, not firm, and not sticky.
Therapeutic Diet Order Not Followed
Penalty
Summary
The facility failed to ensure that Resident 1’s prescribed therapeutic diet was followed. Resident 1 was admitted with diagnoses including COPD with acute exacerbation and Type 2 DM with diabetic peripheral angiopathy without gangrene. The resident’s history and physical indicated the resident did not have the capacity to understand and make decisions, and the MDS showed moderate cognitive impairment, substantial/maximal assistance with ADLs such as eating and oral hygiene, and dependence for some mobility tasks. The order summary showed a physician order for a consistent carbohydrate diet, no added salt, minced and moist texture, with thin liquids. However, the dietary slip for Resident 1 indicated large portions. During interviews, CNA 1 confirmed the dietary slip showed large portions, LVN 2 stated large portions would need to come from the physician, and the Dietary Supervisor stated the large portions notation was carried over from a previous admission and did not match the current diet order. The Dietary Supervisor also stated the slip should have been verified against the current diet order before printing. RN 1 stated all physician diet orders should be followed and verified because only the physician can determine what orders to continue or discontinue once a resident is readmitted.
Fortified Foods Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that a resident with an order for fortified foods received those foods as prescribed. Resident #41 was admitted with diagnoses including moderate protein-calorie malnutrition, encephalopathy, vitamin D deficiency, and muscle wasting and atrophy. The physician order, revised on 02/08/26, directed a regular diet with fortified foods at all meals, including fortified cereal at breakfast and fortified soup or potatoes at lunch and dinner. A nutrition progress note documented significant weight loss and identified fortified food at all meals as an intervention. During observation of the noon meal service, no fortified foods were prepared. Later that day, the evening meal server stated she was unaware of any residents who required fortified foods and did not prepare any for the evening meal. The resident stated she was worried about her weight, did not like the nutrition supplements offered, and had not heard of fortified foods. Another staff member stated no residents in the facility had an order for fortified foods and that none were being served. The RD stated he was not aware the resident had a physician order for fortified foods and explained that fortified foods would add calories to regular foods.
Failure to Provide Ordered Double Portions
Penalty
Summary
The facility failed to provide the necessary care and services to meet a resident's nutritional needs by not implementing a physician-ordered dietary intervention for Resident #76. Facility policy titled Large Portions stated that large portions would be served when ordered by the physician or requested by the consultant dietitian, Director of Food and Nutrition Services, or resident, and that double portions were discouraged but, if ordered, two complete trays would be delivered. Resident #76 stated he was supposed to receive double portions with meals but had not received them since admission. Review of the resident's order summary showed a regular diet with regular texture and regular liquids consistency, along with an active order for double portions. The resident confirmed during interview that he did not receive double portions on his lunch tray, and an observation of the lunch tray showed it did not include double portions. The RD confirmed the physician order for double portions and stated that staff are typically told to give two trays when there is an order for double portions. The resident was admitted with diagnoses including heart failure, and the MDS showed a BIMS score of 10, indicating moderate cognitive impairment.
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