Failure to Implement Therapeutic Diet Results in Resident Death
Summary
A facility failed to ensure that a resident with dysphagia and documented swallowing difficulties received a therapeutic diet consistent with the recommendations of the Speech Language Pathologist (SLP). The resident, who had diagnoses including dementia, dysphagia, and aphasia, was admitted on a regular diet with nectar thick liquids. Multiple SLP evaluations and weekly treatment plans recommended a mechanical soft diet and nectar thick liquids due to poor swallow safety, moderate confusion, and observed difficulties such as holding food in the mouth, coughing or choking during meals, and spitting or spilling food. Despite these recommendations, the resident continued to receive regular textured food. The resident's care plan did not include interventions related to a therapeutic diet, and the diet order in the electronic medical record did not reflect the SLP's recommendations for a mechanical soft diet. Staff interviews revealed a lack of awareness regarding any changes to the resident's diet, with nursing and dietary staff indicating that they were not informed of the SLP's recommendations. The SLP stated that diet communication slips were provided to both dietary and nursing departments, but the new diet recommendation was not effectively communicated or implemented. On the day of the incident, the resident was served a meal that included a hot dog, which is specifically listed as a food to avoid for individuals on a mechanical soft diet. The resident was later found unresponsive and without a pulse after eating, with staff and EMS removing pieces of hot dog from her airway. The resident suffered asphyxiation and expired in the facility. The deficiency was cited under 42 CFR 483.25 for failure to provide adequate nutrition and hydration consistent with the resident's clinical needs.
Removal Plan
- Resident is no longer in the facility.
- Resident was picked up on speech caseload with a goal of consuming regular diet and thin liquids. Resident was discharged from speech with recommendations for mechanically altered diet and thin liquids.
- New diet recommendation not communicated effectively by speech therapist to dietary or nursing departments. Investigation initiated and contracted therapy provider was notified. SLP will be suspended pending investigation. Regional therapist in house for an additional audit of residents on current speech caseload.
- An audit of current resident's diet as well as most current speech recommendations will be completed by Interdisciplinary Team to identify any discrepancies. Discrepancies identified were corrected with recommended speech diets, provider notified, and care plans updated.
- Meal Tracker will also be audited to ensure ordered diets match the tray ticket. Discrepancies identified were corrected.
- Licensed nurses and therapy department were re-educated regarding the expectation that any changes to diet are communicated within the IDT team via diet communication slip. SLP to complete diet communication slip, keep a copy, and give a copy to DOR, CDM, and Nurse Manager.
- Dietary Communication Slips will be reviewed in clinical morning meeting Monday-Friday.
- Administrator/designee will review 3 residents per week, according to MDS assessment per calendar, to validate ordered diet matches most current speech recommendation.
- Facility Administrator/designee will be responsible for the overall implementation and validation of this plan.
- Results of these reviews will be presented to the Quality Assurance Performance Improvement committee for review and recommendations. Any concerns will be addressed at time.
- An Ad Hoc QAPI will be held.
- Medical Director was notified of the incident and plan for improvement.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
The facility did not follow its own weight-monitoring policy or MD orders for several residents with conditions such as COPD, HF, diabetes, and kidney disease. Although orders and care plans required weekly weights for four weeks and then monthly, weights were missing for extended periods, including after admission and readmission, with no refusals documented. In two cases, weights were only obtained at surveyor request, revealing significant weight changes over weeks to months without interim monitoring. The NHA acknowledged that ordered weight monitoring was not properly completed for multiple residents.
Two residents experienced unmet nutritional needs when the facility failed to follow diet orders, monitor weight loss, and provide required meals. A resident with DM and a documented vegetarian diet order received regular diet meal tickets listing meat-based options, had poor intake of facility meals, and experienced a 16.3% weight loss in 19 days without timely documentation, provider notification, or initiation of nutritional interventions, despite policies requiring monitoring of impaired nutrition and unplanned weight loss. Another resident with ESRD on a therapeutic renal dialysis diet left very early for thrice-weekly dialysis and was not provided breakfast or alternative food to take, with EMR entries showing breakfast as not available or not applicable on dialysis days and staff confirming no meals or snacks were prepared, contrary to facility policies requiring at least three meals daily and coordination of nutritional management for dialysis care.
A resident with diabetes, hypertension, and dementia had an original diet order for mechanical soft with low concentrated sweets (LCS), which was later changed by physician order and RD recommendation to a regular diet. Although the EMR and dietary tray card system reflected the regular diet, the nutrition care plan continued to direct staff to provide an LCS, mechanical soft diet and was not updated to match the current order. The clinical record also lacked documented rationale from the physician or RD for discontinuing the LCS therapeutic restriction. Facility leadership and clinical staff confirmed that the individualized care plan and documentation did not reflect the resident’s current nutritional needs and discontinued interventions.
A resident with diabetes, dysphagia, and orders for a pureed diet with nectar‑thick liquids and a CCHO plan had a jar of peanut butter and jelly at the bedside and reported eating it directly from the jar because he disliked facility food. Nursing staff and a CNA knew the resident sometimes ate peanut butter and jelly and was non‑compliant with his diet but did not recognize or act on the conflict with his ordered pureed/nectar‑thick, CCHO diet or his aspiration precautions. The CDM and ST were unaware the resident was consuming peanut butter and jelly and had not evaluated its safety or appropriateness, while the resident’s significant other stated she had been bringing it for months after being told she could bring any food. The facility’s policy requiring interdisciplinary review and documentation when resident food preferences conflict with prescribed diets was not followed, resulting in ongoing access to food inconsistent with the physician’s orders.
The facility failed to provide ordered nutritional supplements with meals for two residents who required assistance and monitoring for nutrition and hydration. One resident with dementia, dysphagia, and severe cognitive impairment, fully dependent on staff for feeding, had orders for a health shake with meals and a magic cup to be given with meals and alternated with bites of food, but was only given the regular breakfast items without the health shake and without the magic cup being offered as ordered. Another resident with hyperkalemia, chronic fatigue, and moderate cognitive impairment, who was at risk for altered nutrition and had an order for a magic cup supplement with each meal, was observed eating breakfast without being offered the supplement. A CNA reported being unaware of some of these supplement orders despite diet cards in the kitchen, and the Administrator reported there was no policy on supplemental orders.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Failure to Monitor and Document Ordered Weights for Multiple Residents
Penalty
Summary
The facility failed to monitor and document resident weights according to physician orders and its own "Weight Protocol" policy, which required weights within 24 hours of admission, weekly for four weeks, and then monthly. One resident admitted in early February with COPD and a communication deficit had a care plan to monitor weights per facility policy and a physician order for weekly weights for four weeks then monthly; however, there was no recorded weight from 2/11 through discharge to the hospital on 2/14, and after readmission and a new order for weekly weights, no weights were documented after 3/3 for March and April, with no refusals noted. Another resident admitted in late March with heart failure and diabetes had a care plan to monitor weights per policy and a physician order for weekly weights for four weeks then monthly, but there were no documented weights after the admission date. A third resident admitted in early February with heart failure and diabetes had a care plan and physician order for weekly then monthly weights, yet only two weights were recorded in early March, and a subsequent weight obtained at surveyor request in April showed a 51‑pound change over 36 days, with no intervening weights documented. A fourth resident admitted in mid‑January with heart failure and kidney disease had a care plan and physician order for weekly then monthly weights, but no weights were recorded after 2/1 for February through April, until a weight was obtained at surveyor request in April showing an approximate 15‑pound change over two months. The Nursing Home Administrator confirmed that the facility failed to properly monitor weights as ordered for four of six reviewed residents.
Plan Of Correction
Residents R15 has discharged from the facility, Residents R18, R29 and R33 will have their weights reviewed by the Dietitian for any changes related to weight increase or decline. Any changes will be reported to the Physician/NP for further orders or plan of care changes. Resident weights will be completed on admission, weekly times 4 and then monthly until a physician order changes this policy. Weights will be reviewed by the Dietitian and DON/Designee. The Dietitian will review for any changes related to weight increase or decline. Any changes will be reported to the Physician/NP for further orders or plan of care changes. Education will be provided by the DON/designee to the nursing staff that resident weight needed to be completed upon admission, then weekly times four and monthly by the 7 th of the month per the weight policy. DON/Designee will complete audits for weights recorded at 90% of resident admissions, weekly weights, and monthly weights and ensure the Dietitian has reviewed the weights for any changes related to weight increase or decline. Any changes will be reported to the Physician/NP for further orders or plan of care adjustments. Results of these audits will be reviewed at the QAPI committee meeting for further recommendations
Failure to Provide Ordered Vegetarian Diet, Address Significant Weight Loss, and Serve Breakfast on Dialysis Days
Penalty
Summary
The deficiency involves the facility’s failure to meet residents’ nutritional needs by not honoring a prescribed vegetarian diet and not responding to significant weight loss for one resident, and by not providing breakfast meals on dialysis days for another resident. One resident with diabetes mellitus was admitted for IV antibiotic therapy after a recent UTI and was identified as at risk for dehydration and nutritional issues. Her baseline care plan and physician orders documented a vegetarian diet, regular texture, and thin liquids, and the care plan instructed staff to monitor and record meal intakes, obtain RD evaluation as needed, and complete weekly weights. Despite this, her MDS showed she did not receive a therapeutic diet, and her meal tickets were printed as a regular diet with meat-based options such as chicken, cheeseburger, hot dog, and sloppy joe, and no vegetarian menu was available. Dietary staff acknowledged they did not have a vegetarian meal ticket for her and had not yet ordered soy burgers, and staff reported difficulty providing her vegetarian diet due to lack of appropriate choices. The same resident’s intake of facility-provided meals was documented as poor, less than 50% of meals, and she was described as very particular about what she ate, with her husband frequently bringing in outside food of unknown amounts. Weights documented in the EMR showed 156.2 lbs on admission and again on a later date, followed by a drop to 132.8 lbs and then a calculated weight of 128.4 lbs when the wheelchair weight was subtracted, representing a significant weight loss of 16.3% in 19 days. The EMR lacked a progress note addressing the weight loss on the date it was first recorded, and nursing documentation showed that when the provider was in the facility shortly after the low weight was obtained, staff updated the provider about low blood pressure but not about the weight loss. The provider was not documented as being notified of the weight loss until several days later, and there was no evidence of re-weighing, appetite stimulant orders, or nutritional supplements being initiated despite existing orders allowing the RD or interdisciplinary team to start supplements. Administrative and dietary staff later reported they were unaware of the weight loss at the time and had not reviewed the resident’s weights. The deficiency also includes failure to provide breakfast meals to another resident with ESRD and moderate protein-calorie malnutrition who received dialysis three times per week. This resident had a therapeutic renal dialysis diet ordered and required set-up assistance for eating, with documentation that his meal intakes were generally good and adequate to meet estimated needs. His EMR showed multiple breakfast meal entries on dialysis days marked as “not available” or “not applicable,” and staff interviews revealed that he left very early for dialysis and was not provided breakfast or a snack to take with him. The resident reported he did not eat breakfast before dialysis because none was provided, and he did not receive a snack at the dialysis center. CNAs and an LN confirmed that no actual breakfast meal was prepared for him on dialysis mornings, the kitchen was closed at the time he woke up, and no alternative food or drinks were offered to take with him. The facility’s own policies on dialysis care and frequency of meals required communication about nutritional management and provision of at least three meals daily at regular times or according to resident needs and care plan, but these were not followed for this resident on dialysis days. The facility’s Nutrition (Impaired)/Unplanned Weight Loss clinical protocol required monitoring and documenting weight and dietary intake in a way that allowed ready comparison over time, defining current nutritional status through interdisciplinary assessment, and using supplementation strategies such as food fortification and increased portions for residents with impaired nutrition or risk factors. For the resident with significant weight loss and a vegetarian diet order, the record and interviews showed that although poor intake and vegetarian preference were known, the facility did not adjust menus to provide appropriate vegetarian options, did not consistently document or act on poor intake, and did not promptly assess or intervene when substantial weight loss occurred. For the resident on dialysis, the facility’s Dialysis, Care for a Resident policy required communication about nutritional and fluid management, and the Frequency of Meals policy required at least three meals or their equivalent daily, but staff acknowledged that no breakfast meal or equivalent was prepared or offered on dialysis mornings, and refusals were not documented in the EMR or care plan.
Failure to Update Care Plan and Document Rationale for Diet Change
Penalty
Summary
Surveyors identified that the facility failed to update an individualized care plan to reflect a resident’s current diet order and failed to address discontinued resident-specific nutritional interventions. Facility policies required that diet orders be provided as ordered by the healthcare provider, that the tray card system match the medical record, and that comprehensive care plans be updated on an ongoing basis to reflect resident needs, wishes, or changes in condition. The resident involved had diagnoses including diabetes mellitus, hypertension, and dementia. A Medical Nutritional Therapy assessment documented a diet order of mechanical soft with low concentrated sweets (LCS). A clinical progress note later recommended advancement to regular solids and thin liquids, and the physician order for LCS, mechanical soft was discontinued and replaced with a regular diet order. The facility’s EMR diet order report and the dietary tray card system both showed a regular diet for the resident. Despite these changes, the resident’s nutrition status care plan, last updated several days before the diet change, continued to list an intervention to provide an LCS, mechanical soft texture diet and was not revised to reflect the current regular diet order. The RN Assessment Coordinator confirmed that the care plan did not match the current diet order. A subsequent RD progress note also indicated the resident was on a regular diet, but the clinical record did not contain documentation from the RD or physician providing a rationale for discontinuing the LCS therapeutic diet restriction. The Regional Risk staff member confirmed the absence of this rationale in the record, and the Administrator and DON acknowledged that the facility failed to update the individualized care plan to address the resident’s specific nutritional concerns and preferences and failed to address the discontinued resident-specific interventions.
Failure to Control Off‑Diet Peanut Butter and Jelly for Resident on Pureed, Nectar‑Thick, CCHO Diet
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food available to a resident was consistent with the physician‑ordered pureed diet with mildly thick (nectar‑thick) liquids and a consistent carbohydrate (CCHO) plan. The resident had multiple diagnoses, including diabetes mellitus, anemia, atrial fibrillation, acute respiratory failure with hypoxia, and chronic kidney disease, and was on aspiration precautions with safe swallowing instructions posted at the bedside. Despite these orders and precautions, surveyors observed a jar of Smucker’s Goober Strawberry Peanut Butter & Jelly Stripes on the resident’s bedside table within reach. The resident reported that he did not like the pureed food served by the facility, acknowledged having difficulty swallowing, and stated that he had been eating peanut butter and jelly directly from the jar since the previous year without being told it could be unsafe. Nursing and CNA staff were aware that the resident was sometimes non‑compliant with the prescribed diet and had seen him eating peanut butter and jelly, but they did not recognize or act on the potential conflict with his ordered pureed/nectar‑thick, CCHO diet. The LN confirmed the resident’s diet order and aspiration precautions, acknowledged seeing him eat peanut butter and jelly, and admitted uncertainty about whether it was safe. The CNA stated that the resident did not like the pureed food, had observed him eating peanut butter and jelly as a snack, and knew he was sometimes non‑compliant with his diet, but was not aware of his swallowing precautions and did not know that peanut butter and jelly could be unsafe for him. Neither staff member reported the issue through the facility’s processes or sought further assessment of the resident’s swallowing in relation to this food. The dietary and therapy departments were also not informed of the resident’s ongoing consumption of peanut butter and jelly. The Certified Dietary Manager, upon review of the electronic health record, confirmed the resident’s CCHO diabetic dysphagia diet with pureed texture and nectar‑thick liquids and stated that peanut butter and jelly did not meet the physician‑ordered diet due to both texture and sugar content. The Speech Therapist reported that she had not evaluated the resident for some time, was unaware that he was eating peanut butter and jelly directly from the jar, and had never assessed his ability to safely swallow that food. The resident’s significant other stated that she had been bringing peanut butter and jelly for about three months, that staff had told her she could bring any food she wanted, and that she continued to bring it because the resident would not eat otherwise, despite being aware there could be safety concerns. The facility’s policy on resident food preferences required the dietitian and nursing staff, with physician involvement, to address conflicts between resident preferences and prescribed diets, but this process was not implemented in relation to the resident’s peanut butter and jelly consumption. Overall, the facility did not ensure that the resident’s available food was consistent with the ordered pureed, nectar‑thick, CCHO diet, did not communicate or coordinate among nursing, dietary, and therapy staff regarding the resident’s off‑diet food brought by family, and did not follow its own policy for managing resident food preferences that conflict with prescribed diets. This resulted in the resident having independent access to and consuming peanut butter and jelly that did not conform to his physician‑ordered diet and swallowing precautions.
Failure to Provide Ordered Nutritional Supplements With Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nutritional supplements to residents as specified in their physician orders and care plans. One resident with severe cognitive impairment, dementia, depression, dysphagia, and dependence on staff for feeding had care plan interventions for staff to feed all meals and snacks and physician orders for a regular diet with pureed texture and mildly thick liquids. The care plan and orders included a health shake with meals for weight gain and a magic cup with meals, to be offered alternating with bites of food per speech therapy. During a breakfast observation, the resident was fed oatmeal, eggs, fruit, and thickened juice by a CNA, but the magic cup was not provided in between bites of food, and the health shake was not provided at all. The CNA confirmed awareness that the resident should receive a magic cup but did not know it was to be given between bites and was unaware of the health shake order, despite diet orders being available in the kitchen. Another resident with hyperkalemia, chronic fatigue, weakness, moderate cognitive impairment, and risk for altered nutrition and hydration status had care plan interventions to offer substitutes when meal intake was less than 50%, monitor weights, and provide nutritional supplements as ordered. The resident’s diet had been changed from mechanically altered to regular with thin liquids, and there was a physician order for a magic cup supplement with meals. During a breakfast observation, the resident was seen eating eggs, bacon, and toast without being offered a magic cup. The CNA later confirmed that the diet card indicated the resident should receive a magic cup with each meal but acknowledged that the supplement was not offered and that they were unaware of the order. The Administrator stated there was no policy on supplemental orders. This deficiency was cited under a complaint investigation.
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