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:
Therapeutic Diet Order Not Followed: A resident with DM had an ordered CCHO, regular texture, thin consistency, vegetarian diet, but the meal tickets for breakfast and lunch did not match the order. The trays included items such as hashbrowns and cake, and the RD and Dietary Manager confirmed the meal tickets did not reflect the physician's orders. An LVN stated the resident's blood sugars ranged up to 400 mg/dL and that not receiving the prescribed CCHO diet contributed to elevated blood sugar levels.
Therapeutic Diet Not Served as Ordered: A resident with ESRD on dialysis and muscle weakness had a physician order for large portions, boiled eggs at breakfast, and double meat for protein. Meal observations showed the resident received only one boiled egg and one sausage patty at breakfast and two chicken wings at lunch, which the DS and RD confirmed were not the ordered double portions.
A resident with dementia, DM II, CKD, and muscle wasting was ordered a regular diet with mechanical soft, ground texture, and ice cream with lunch and dinner, but observations showed the ice cream was missing from her meal tray. An LVN confirmed the resident did not receive the ordered ice cream, and the FSM and DON acknowledged that the ice cream should have been served as ordered.
Ordered Pureed Diet Not Provided: A resident with cerebral infarct, muscle weakness, and dysphagia was ordered a pureed texture diet with nectar thick liquids, and the care plan directed staff to provide the diet as ordered. During breakfast, the resident was observed eating scrambled eggs with a lumpy texture instead of the ordered pureed omelet, and an RN confirmed the tray did not match the meal ticket or the physician-ordered diet.
Prescribed nutritional supplements were not provided to two residents. One resident had dysphagia, respiratory failure, and weight loss, and another had heart failure and significant recent weight loss; both had MD orders for Magic Cups. During meal observations, their trays had no Magic Cups even though the meal tickets listed them, and dietary staff said the facility was out of Magic Cups and substituted ice cream instead, which the RD confirmed was not the same nutritive value.
Therapeutic diet orders were not followed for a resident with DM, dementia, COPD, and HTN. The hospital discharge paperwork ordered a carbohydrate-controlled diet, but the facility entered a regular diet in the EHR instead. The DON confirmed the diet order was entered incorrectly and that the resident did not receive the correct diet until the order was later changed to a consistent carbohydrate diet.
Therapeutic Diet Order Not Reflected on Meal Tickets
Penalty
Summary
The facility failed to ensure that Resident 1 received the physician-ordered therapeutic diet. Resident 1 was admitted and readmitted to the facility with diagnoses including type 2 diabetes mellitus and muscle weakness. The history and physical noted fluctuating capacity to understand and make decisions, while the MDS indicated the resident was able to understand and be understood by others and was independent with eating, oral hygiene, and toileting hygiene, with varying levels of assistance needed for other activities of daily living and mobility. Resident 1 had an order for a carbohydrate controlled diet, regular texture, thin consistency, and vegetarian (lacto/ovo) diet. During observation and interview, the breakfast and lunch meal tickets on the tray did not reflect the ordered diet. The breakfast tray included a breakfast slider, two fried eggs, and hashbrowns, and the lunch tray included brown rice, green beans, tofu with sliced carrots, and one white cake with jelly. Resident 1 stated she had asked the kitchen not to give her potatoes because of too many carbohydrates, and her meal ticket did not indicate no potatoes that day. The Dietary Manager stated the order listing report showed the CCHO, regular texture, thin consistency, vegetarian diet, but the breakfast and lunch meal tickets did not match because the information entered in the system was not printing both diets on the resident's meal ticket. The RD reviewed the meal tickets, order listing, and therapeutic spreadsheet and stated the meal ticket did not reflect the physician's orders and the resident was not served CCHO servings as listed on the therapeutic spreadsheet. LVN 1 stated Resident 1's blood sugars for the month ranged from 105 mg/dL to 400 mg/dL and stated the resident did not receive the prescribed CCHO diet, which had led to elevated blood sugar levels.
Therapeutic Diet Not Served as Ordered
Penalty
Summary
The facility failed to ensure that Resident Identifier (RI) #3 received double portions of protein as ordered for a therapeutic diet. RI #3 was admitted with diagnoses of End Stage Renal Disease, dependence on renal dialysis, and muscle weakness. The resident’s admission MDS, with an ARD of 05/25/2026, indicated cognitive intactness and coded the resident as receiving a therapeutic diet. A physician’s order dated 05/26/2026 directed large portions to each meal tray, including boiled eggs on the breakfast tray and double meat on each tray for protein. During meal observations on 06/24/2026, RI #3’s breakfast tray contained one boiled egg and one thin turkey sausage patty, and the resident stated that his/her protein was low and the doctor had ordered more protein a few days earlier. At lunch, the tray contained two chicken wings. The Dietary Supervisor stated RI #3 should have received two boiled eggs and two servings of meat at breakfast, and that the two wings were only one serving, not a double portion, describing the issue as a kitchen mistake. The Registered Dietician later stated that four wings should have been served and confirmed that dietary staff were responsible for ensuring residents received double portions as ordered.
Ordered therapeutic diet item not served with meal tray
Penalty
Summary
Therapeutic diets were not consistently provided as ordered for Resident #62, who had diagnoses including muscle wasting, dementia, diabetes II, and chronic kidney disease. Her record showed a BIMS score of 7/15, supervision or touching assistance needed with eating, and no weight loss on the MDS. Her consolidated orders for June 2026 included a regular diet with mechanical soft, ground texture, and ice cream for lunch and dinner, and her care plan also directed that she receive regular diet, mechanical ground meat texture, and regular consistency ice cream with lunch and dinner due to potential nutrition and weight loss concerns. During lunch observations, Resident #62’s meal card listed a 4 oz ice cream cup, but she did not receive ice cream on her tray. An LVN was observed assisting her with cutting steak, and confirmed that the resident did not have the ordered ice cream on her lunch tray. A later observation again showed the resident was not served ice cream with her lunch meal. The FSM stated that ice cream should be on the tray when the resident is served her meal, and the DON stated the resident should have ice cream on her meal tray and that it had been ordered for weight loss. The facility policy stated that a written order must appear on the medical record before the resident may be served.
Ordered Pureed Diet Not Provided
Penalty
Summary
The facility failed to ensure a resident received a mechanically altered diet as ordered by the physician. Resident #69 had diagnoses including cerebral infarct, muscle weakness, and dysphagia, and the admission MDS indicated impaired cognition and a mechanically altered diet. The care plan identified increased nutrition/hydration risk and directed staff to provide the diet as ordered. The active physician’s order required a pureed texture diet with nectar thick liquids. During breakfast observation, the resident was eating in her room with no staff present. The meal ticket on the tray indicated a pureed baked omelet, but the resident’s plate contained scrambled eggs with a lumpy texture, which she was consuming. RN #300 observed the tray and confirmed that scrambled eggs were present instead of the ordered pureed omelet. The facility’s puree food preparation guidance stated puree products are to be maintained between a pudding-like or mashed potato equivalent thickness.
Prescribed Nutritional Supplements Not Provided
Penalty
Summary
The facility failed to ensure two residents received their prescribed nutritional supplements. Resident 27 had diagnoses including gastritis, dysphagia, and respiratory failure, had unanticipated weight loss, and was on a mechanically altered diet. Resident 27’s care plan included providing nutritional supplements as ordered by the physician, and the physician’s order report indicated Magic Cups twice daily for risk of malnutrition. Resident 35 had diagnoses including heart failure, low blood pressure, and muscle weakness, had a history of weight loss, and was documented as having lost 13 pounds between 4/30/26 and 5/13/26. Resident 35’s care plan included increasing Magic Cup to three times a day, and the physician’s order report indicated Magic Cups with meals for malnutrition. During dining and tray line observations, both residents’ lunch meal tickets indicated Magic Cup with the meal, but no Magic Cup was placed on either tray. The Dietary Manager stated the facility was out of Magic Cups and had not known they were out. Dietary staff stated they substituted ice cream for the Magic Cup, and later stated there were still no Magic Cups available. The Dietary Manager stated the facility ran out because nursing asked dietary aides to give extra Magic Cups that were not physician ordered. The Registered Dietitian stated Magic Cups were to be given only to residents with physician orders and confirmed that ice cream was provided in place of Magic Cups, but was not of the same nutritive value.
Therapeutic Diet Order Not Followed
Penalty
Summary
Therapeutic diet orders were not followed for one resident who was reviewed for therapeutic diets. The resident was admitted with diagnoses including Diabetes Mellitus, Dementia, Chronic Obstructive Pulmonary Disease, and Hypertension. The hospital discharge orders documented a Carbohydrate Controlled Diet, but the facility's Physician's Order in the Electronic Health Record documented a Regular diet on 4/20/26. A later Physician's Order dated 5/5/26 changed the diet to a Consistent Carbohydrate Diet. During interview on 6/18/26, the DON stated the facility should have followed the diet order on the hospital discharge orders and verified that the resident's diet order was not entered correctly on 4/20/26 and that the resident did not receive the correct diet until 5/5/26.
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