Failure to Follow Prescribed Diet Leads to Choking Incident
Summary
The facility failed to ensure that a resident on a prescribed dysphagia mechanical soft consistency diet was provided with the appropriate food texture, leading to a serious choking incident. The resident, who had a history of Parkinson's disease, dysphagia, and other medical conditions, was allowed to consume a peanut butter and jelly sandwich, which was not suitable for her dietary needs. This oversight occurred when a Certified Nursing Assistant (CNA) left a tray of snacks, including the sandwich, unattended in the dayroom, and the resident, known for grabbing food from others, took the sandwich and began to eat it. The CNA, aware of the resident's dietary restrictions, mistakenly believed the sandwich was soft enough for the resident to consume because she had seen her eat bread before. However, the resident began to choke on the sandwich, leading to a severe medical emergency. The resident was found unresponsive with a low oxygen saturation level, and despite attempts to administer the Heimlich maneuver and suction food from her airway, she required emergency medical intervention. Paramedics were called, and the resident was transported to the hospital, where she was admitted to the Intensive Care Unit with acute respiratory failure due to hypoxia. The incident highlighted a critical lapse in following prescribed dietary orders and ensuring staff were adequately trained and knowledgeable about the specific dietary needs of residents. The CNA involved had not received proper education on the types of foods appropriate for a dysphagia mechanical soft diet, which contributed to the resident's choking incident. The facility's failure to adhere to the resident's dietary requirements resulted in substandard quality of care at the Immediate Jeopardy level.
Removal Plan
- CNA A received a teachable moment regarding appropriate snacks according to diet texture with the DON.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the action plan. The Medical Director reviewed and approved the plan.
- The RD completed a quality review on residents diet orders and validated with the CDM against the kitchen's meal ticket identifiers to ensure that diets were being served as prescribed. Orders were clarified as needed.
- Resident diet orders were posted in pantry rooms and dining rooms. Print outs listing approved snacks for regular texture, dysphagia advanced, dysphagia mechanical soft, and dysphagia pureed were posted to dining rooms, nursing stations, and med carts. The CDM validated that snacks were delivered to the secured pantry.
- Education for staff started and continued. They educated staff on appropriate snacks based on resident diet texture order and the procedure to validate the resident's diet order if needed. Training also included Abuse/Neglect training and supervision during snack pass. Newly hired staff would receive education during orientation regarding appropriate snacks to be offered based on diet texture orders.
- The CDM completed 100% training with dietary staff regarding meal ticket accuracy and procedures for snacks. New diet orders would be reviewed during morning clinical meeting.
- Unit Managers began weekly audits to ensure appropriate snacks were being passed, meal tickets matched what was being served, and staff was able to verbalize where to find correct diet information. Audits were done with no discrepancies noted.
- A facility wide quality review was begun by Speech Language Pathologist to verify that residents with dysphagia diagnosis were on the correct texture diets. The audit was completed with no discrepancies noted.
- Resident #1 returned to the facility from the hospital with diet texture downgraded to puree. Orders and care plans were updated accordingly to reflect the texture change. The RD followed up with resident #1 with no new recommendations.
- NHA and Interdisciplinary Team (IDT), including Medical Director, met for monthly QAPI meeting and to review the progress made. They determined that all plans that had been put in place were effective.
- The RD completed the second quality review to ensure diet orders in the electronic medical record matched the meal tracker. There were no issues noted.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a feeding tube, severe cognitive impairment, quadriplegia, and persistent vegetative state did not receive enteral water at the ordered rate. Staff observed the pump set at 30 ml/hr even though the physician order was for 45 ml/hr for 22 hours with 2 hours of gut rest. An LVN confirmed the incorrect rate and stated he was not aware of any order change, while the DON and ADM stated nurses were responsible for checking orders and pump rates.
Failure to Provide Ordered Nutritional Supplement: A resident at risk for malnutrition did not receive a physician-ordered frozen nutritional treat with lunch and dinner. Observations showed the meal trays contained food and drinks but no supplement, and the resident stated she was not getting any frozen nutrition treat. Staff interviews revealed the order was not communicated to the kitchen program and was not appearing on the meal ticket; the kitchen manager said changes depended on nursing communication, and the DON said the CDM typically ensured items were on the tray.
A resident with DM, weakness, and right-sided hemiplegia after a stroke had a 20% body weight loss and appeared gaunt and thin. Meal intake was under 50% on many days, but there was no documentation that meal replacement was offered, the Kardex lacked that intervention, and the IDT care conference did not result in any documented weight-loss strategies or feeding tube plan.
Missed Weekly Weights for Resident With Significant Weight Loss: A resident with tube feeding, poor PO intake, dysphagia, and a history of significant weight loss had a physician order for weekly weights due to weight change, but multiple weekly weights were not recorded. The RD noted the resident had lost weight when TF was reduced and that family snacks may have contributed to weight gain, while the dietary note documented ongoing supplements, bolus Jevity 1.5, and a 6-month unplanned weight loss of 25.6 lbs.
Fluid restriction orders were not implemented or documented correctly for two residents. One resident with DM and ESRD had conflicting MAR and nursing documentation for a 1500 mL fluid restriction, with no clear total amount and inconsistent amounts from dietary vs nursing. Another resident with DM, dysphagia, and HTN had hospital discharge orders for a 1.6 L/day fluid restriction, but the EHR care plan and diet orders did not include it, and staff said it should have been implemented or clarified on admit.
The facility failed to maintain nutrition status for two residents. One resident with CHF, COPD, hepatitis C, and cognitive impairment reported hunger and said he was supposed to receive large portions, but no large-portion order was in place and his significant weight loss was not identified or verified until later. Another resident with ESRD, CHF, malnutrition, and hemodialysis had a daily weight order for fluid overload, yet multiple weights were not obtained or documented, and the resident was not on the dietician follow-up list.
Incorrect Enteral Hydration Rate
Penalty
Summary
The facility failed to offer sufficient fluid intake to maintain proper hydration for Resident #6 and did not follow the physician’s enteral hydration order. Resident #6 was a male admitted with acute and chronic respiratory failure, quadriplegia, and persistent vegetative state. His quarterly MDS showed a BIMS score of 00 and that he had a feeding tube. His care plan identified a potential fluid deficit related to depending on staff for water via g-tube, with an intervention to administer fluids per g-tube as ordered. The order summary showed an order dated 03/27/2026 for H2O 45 ml/hr for 22 hours with 2 hours of gut rest. During observations on 06/09/2026 and 06/10/2026, the feeding pump screen displayed H2O at 30 ml/hr instead of the ordered 45 ml/hr. During interview, LVN A confirmed the pump was set at 30 ml/hr and stated he was not sure why it was set that way and was not aware of any order changes. He later stated he was not aware the rate was wrong and that nurses were responsible for setting the correct rate and monitoring the pump. The DON stated nurses should check the orders and rates every shift and when hanging a new bag, and the ADM stated nurses were to monitor the feeding pump rate daily and when new bags were hung. The facility policy on enteral nutrition stated nursing services were responsible for feeding equipment and administration of tube feedings, and that problems with tube feeding administration were monitored and corrected by nursing.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to provide a physician-ordered frozen nutritional treat with lunch and dinner for one resident who was identified as at risk for malnutrition. During observations on 6/8/2026 and 6/9/2026, the resident was eating lunch in her room and the meal trays contained food and beverages, but no frozen nutritional treat was present. The resident stated she did not get any additional nutrition treat and nothing that was frozen. The resident’s physician order dated 11/26/2025 directed a frozen nutritional treat with lunch and dinner two times a day for risk for malnutrition. The medical record showed weights of 187.4 lbs on 5/23/2026, 194.6 lbs on 4/13/2026, 189.8 lbs on 2/22/2026, and 196.1 lbs on 11/30/2026, and the dietary/nutrition evaluation dated 6/4/2026 documented weight as stable and listed current nutritional supplements as magic cup BID. Staff interviews indicated the treat was normally sent from the kitchen, but the order had not been communicated to the kitchen program and was not appearing on the meal ticket. The kitchen manager stated the change would be made only if nursing sent the communication form, and the DON stated the CDM typically pulled the order and ensured everything was on the tray.
Failure to Address Significant Weight Loss and Poor Intake
Penalty
Summary
The facility failed to timely assess, investigate, and implement interventions for significant weight loss for Resident 112, who was admitted with diagnoses including uncontrolled diabetes, weakness, and right-sided hemiplegia and hemiparesis due to a stroke. The resident was able to make needs known. On 06/04/2026, the resident appeared gaunt and thin. The electronic health record showed weights of 184 pounds on 03/14/2026, 150 pounds on 04/11/2026, and 146 pounds on 04/19/2026, reflecting a 20 percent loss in total body weight. The care plan directed staff to monitor meal intake and offer a meal replacement if the resident ate less than 50 percent. Nutritional intake documentation showed the resident had less than 50 percent intake for one or more meals on 26 of 31 days in March 2026, 15 of 30 days in April 2026, and for 28 days from 05/14/2026 to 06/09/2026. The record contained no documentation that meal replacement was offered during March, April, May, or June 2026, and the Kardex did not include an intervention to offer meal replacement. A dietary note on 04/21/2026 stated the resident was triggering for significant weight loss and that a feeding tube would be discussed at the 04/29/2026 care conference, but the care conference documented no concerns, changes, or questions, and no feeding tube or other weight loss strategies were implemented. A nutritional assessment on 05/07/2026 noted unintentional weight loss, swallowing difficulty, self-feeding difficulty, and mild-moderate wasting in the temples and orbitals, with the resident appearing to have looser-fitting clothes and being thin.
Missed Weekly Weights for Resident With Significant Weight Loss
Penalty
Summary
The facility failed to obtain and document weekly weights for Resident #13, who had a physician order dated 03/19/2026 to weigh weekly due to a significant weight change. Review of the resident’s weight record showed multiple missed weekly weights, including no recorded weights on 05/29/2026, 05/22/2026, 05/08/2026, 04/13/2026, and 03/30/2026. The resident’s documented weights showed fluctuations, including 176.6 pounds on 05/15/2026, 172.8 pounds on 05/01/2026, 171.2 pounds on 04/27/2026, 171.0 pounds on 04/20/2026, 177.4 pounds on 04/06/2026, 176.2 pounds on 03/23/2026, 176.8 pounds on 03/18/2026, 178.0 pounds on 03/09/2026, and 177.4 pounds on 03/05/2026. Resident #13 was admitted from the hospital with tube feeding and a diet, ate little, and had a history of significant weight loss. The regional RD stated the resident had lost weight when tube feedings were reduced and that family brought in snacks, which she believed contributed to weight gain. The dietary progress note dated 05/07/2026 documented NAS diet, regular texture, thin liquids, health shake supplements twice daily, and bolus Jevity 1.5 tube feeding twice daily, with current body weight of 172.8 pounds on 05/01/2026 and a 6-month weight history showing 198.4 pounds on 11/26/2025, reflecting a 25.6-pound, 12.9% unplanned, undesirable weight loss. The care plan included risk for malnutrition related to significant weight loss and dysphagia, with interventions including weights per facility protocol and as ordered.
Fluid restriction orders were not implemented or documented for two residents
Penalty
Summary
Fluid restrictions were not implemented or documented correctly for 2 of 4 residents reviewed for nutrition. Resident 103 was admitted with diabetes, leg amputation, and end stage renal disease and was able to communicate needs. The EHR showed a provider order for a 1500 mL fluid restriction, with 900 mL from dietary and 600 mL from nursing per day, but the May 2026 MAR showed a different order for water restriction of 1500 mL for nursing only, broken into 600 mL in the morning, 600 mL in the evening, and 300 mL at night. Nursing documentation did not show a total amount and contained conflicting amounts for what was provided by dietary versus nursing. Staff stated the documentation should have been clearer and should have included a total amount, and the DON stated the documentation did not meet expectations. Resident 2 was admitted with diabetes, dysphagia, and hypertension and was able to make needs known. The EHR showed a diet order for a liberal renal diet with easy-to-chew texture and thin liquids, but no fluid restriction order. The nutritional care plan included offering and encouraging fluids of choice and did not include fluid restriction, even though hospital discharge orders listed a 1.6 liter per day fluid restriction. The RD noted the hospital had the resident in fluid restriction and planned to follow up with the provider, and a cardiology note later referenced fluid restriction per nephrology guidance. Staff stated the hospital discharge fluid restriction should have been implemented or clarified on admission and that it should have been addressed earlier.
Failure to monitor weight loss and nutrition status
Penalty
Summary
The facility failed to maintain acceptable nutritional status and electrolyte balance for two residents reviewed for nutrition status. One resident with chronic diastolic CHF, chronic hepatitis C, COPD, and moderate cognitive impairment was observed to appear thin, gaunt, and emaciated, with spindly limbs. He stated he was supposed to receive large portions, that he was not getting them, and that he felt hungry after meals. However, during observation of his lunch tray, the meal ticket showed no note for large portions, the tray contained a regular portion, and the resident ate 100% of the meal. Record review showed no physician order for large portions at that time. The same resident’s weight record showed 118.8 lbs on 05/13/2026, and the facility did not identify or verify the significant weight loss until later. A reweigh on 05/27/2026 showed 116.2 lbs, and the resident’s EMR showed no RD notes since 01/28/2026. The resident’s care plan identified him as at risk for malnutrition and included consultation with the RD and intervention with weight loss, but he was not on the facility’s list of residents being followed by the dietician company. A physician order for RD consult related to weight loss and an order for mirtazapine for appetite stimulation were entered only after the surveyor requested the resident be weighed. The second resident had acute kidney failure, ESRD, acute on chronic systolic CHF, moderate protein calorie malnutrition, and required hemodialysis. The physician order dated 05/01/2026 directed daily weight monitoring for fluid overload, but the MAR-TAR showed multiple dates with no weights documented. The first recorded weight was 126.2 lbs on 05/06/2026 and later 115.7 lbs on 05/27/2026. The resident’s care plan identified malnutrition risk and included weighing as indicated and documenting/intervening with weight loss, but the facility’s weight list did not include this resident, and staff stated there were no weekly weights obtained or logged for any resident because they had been working on the floor as CNAs and had not had time to complete the weights.
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