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:
Failure to Notify PCP and Family of Significant Weight Loss: A resident experienced significant weight loss after admission, with weights showing a marked decline over time and no weight-loss interventions in the care plan. Nursing and dietary notes documented continued monitoring and notification of the RD, but there was no documentation that the PCP or resident representative was notified about the 9.2% loss in 30 days, and the record lacked further weight-related follow-up.
Failure to monitor weight and nutrition status: one resident did not have a required weight evaluation, and two residents had significant weight loss without reassessment or new nutritional interventions. One resident with neurologic disease and malnutrition developed a coccyx pressure area that worsened, while another resident with diabetes, anemia, and malnutrition lost weight despite a supplement order. The DON and NHA confirmed the failures.
Failure to monitor significant weight loss and follow nutritional interventions. Two residents had documented weight loss that triggered facility policy for weekly weights and reweighing within 24 hours, but one resident was not weighed weekly after a major loss and a dietitian's order to increase Ensure was not implemented. Another resident with Alzheimer's disease and dysphagia had an MNA score indicating malnutrition, then lost 4.5 pounds in one week without a documented reweigh or notification to the MD or responsible party.
Failure to Complete RD Nutritional Assessments: The facility did not complete required admission nutritional assessments by an RD for two residents. One resident had a femur fracture, falls, and pulmonary disease, and another had renal dialysis dependence, sepsis, and a colostomy. Facility policy required an RD assessment within 72 hours of admission, but staff reported the facility had no current RD on staff after the prior RD resigned, and the DON confirmed the assessments were not completed.
Failure to Maintain Resident Weights: Surveyors found that multiple residents had ongoing poor PO intake and significant weight loss. One resident on comfort-focused care picked at meals and had severe weight loss; another with dementia and dysphagia slept through meals, left trays untouched, and did not receive feeding assistance during observation; a third with CHF, DM2, and dysphagia said the pureed food was cold and bland and returned trays; a fourth with dysphagia and a G-tube had choking and swallowing difficulty with pureed foods; and a fifth with stroke-related weakness said she disliked the food and wanted salt. Chart review showed repeated weight loss, nutrition notes, and RD interviews documenting inadequate intake, supplements, and interventions that did not address the stated causes of poor intake.
Failure to Follow Feeding Assistance and Swallowing Orders: A resident with severe cognitive impairment, malnutrition, and dysphagia was supposed to receive meal assistance, no straws, and supervised feeding with modified liquids and textures. Surveyors observed staff setting up meals and leaving the resident alone, and also observed the resident using a straw despite restrictions. Therapy and the DOR stated the resident needed supervision, cueing, and staff present during meals, while an LPN confirmed medications were being given whole in applesauce without a physician order.
Failure to Notify PCP and Family of Significant Weight Loss
Penalty
Summary
The facility failed to assess the cause of a significant weight loss and failed to notify the PCP and resident representative for Resident #8. The resident’s MDS documented admission to the facility on 5/29/26 with a weight of 182 lbs. and identified significant weight loss without a physician-prescribed weight loss regimen. The resident’s weight log showed weights of 210.8 lbs. on 5/29/26, 207.6 lbs. on 5/31/26, 195.8 lbs. on 6/7/26, 178 lbs. on 6/25/26, 180.4 lbs. on 7/5/26, 179.6 lbs. on 7/26/26, 174.6 lbs. on 8/2/26, and 176.8 lbs. on 8/9/26, reflecting a 16.1% weight loss since admission. The care plan lacked interventions related to weight loss. The Nutrition/Dietary Progress Note on 6/7/26 documented a 4.5% weight loss since admission and stated staff would continue monitoring weight. A later note on 6/17/26 documented transfer to a short-term medical facility, and a note on 6/25/26 documented return from the hospital. The Nutrition/Dietary Progress Note on 7/15/26 documented a 9.2% weight loss in 30 days, noted no nutritional supplements were provided, stated staff would continue monitoring, and documented that the Dietitian was notified. The progress notes did not document notification of the PCP or resident representative regarding the 9.2% weight loss, and they lacked further documentation addressing weight.
Failure to Monitor Weight and Nutrition Status
Penalty
Summary
The facility failed to properly monitor residents’ weight and nutrition status. Review of the facility policy indicated that any weight change of 5% or more since the last weight assessment was to be retaken the next day for confirmation and, if verified, nursing was to notify the dietician in writing. For Resident R6, the clinical record showed a physician order for weekly weights, but the weight record from 6/28/26 through 8/4/26 did not include a weight evaluation, and the facility failed to obtain a monthly weight. For Resident R97, the record showed diagnoses including Progressive Supranuclear Palsy, stroke history, cognitive deficit, and malnutrition. The resident lost 7.5 pounds, or 6.05%, from 7/5/26 to 8/1/26, and developed a 1 cm x 1 cm open area on the coccyx on 7/1/26 that worsened by 7/28/26. The dietician had last assessed the resident on 5/15/26 and did not reassess after the pressure ulcer developed or identify nutritional interventions. For Resident R9, the record showed diagnoses including diabetes, anemia, and malnutrition, with Glucerna ordered for weight stabilization. The resident lost 11.3 pounds, or 8.29%, in one month and 17.5 pounds, or 12.28%, in three months, but the dietician confirmed no reassessment or new interventions were put in place to address the weight loss.
Failure to Monitor Significant Weight Loss and Follow Nutritional Orders
Penalty
Summary
The facility failed to consistently monitor resident weights and implement nutritional interventions after significant weight changes were identified for two residents. Facility policy required residents with a weight gain or loss of three pounds or more to be reweighed within 24 hours, with notification to the physician and dietary manager or registered dietitian if the change was confirmed. Resident 43, who had chronic kidney disease, weighed 103.8 pounds on May 15, 2026, then returned from hospitalization on June 1, 2026 at 96 pounds, a 7.5% loss over 16 days, and later weighed 92.4 pounds on June 16, 2026. The record did not show a weekly weight during the week of June 8, 2026 as required after the significant loss. A dietary progress note for Resident 43 documented unplanned significant weight loss and recommended increasing Ensure from twice daily to three times daily, but the record did not show that this recommendation was implemented. Resident 87, who had Alzheimer's disease and dysphagia, had a Mini Nutritional Assessment score of 5, indicating malnutrition. After a DON discussed declining appetite and weight loss with the resident's spouse and responsible party, the spouse requested weekly weights. The resident then weighed 142.3 pounds and 137.8 pounds one week later, a 4.5-pound loss, but the record did not show a reweigh within 24 hours or documentation that the physician or responsible party was notified of the significant weight loss.
Failure to Complete RD Nutritional Assessments
Penalty
Summary
The facility failed to complete a comprehensive nutritional assessment by a registered dietitian for two residents. One resident was admitted with diagnoses including a left femur fracture, falls, and pulmonary disease, and an admission MDS was completed, but the clinical record did not show that a comprehensive nutritional assessment had been completed by an RD for that assessment. Another resident was admitted with diagnoses including dependence on renal dialysis, sepsis, and a colostomy, and although an admission MDS was completed, the record also did not reveal a comprehensive nutritional assessment completed by an RD for the MDS. Facility policy stated that residents were to receive an admission nutritional assessment by an RD, initiated within 72 hours of admission and completed by the ARD. During interviews, the Food Service General Manager was unable to identify the current clinical RD, and the Nursing Home Administrator stated the facility did not currently have an RD on staff because the prior RD resigned and a replacement had not been hired. The DON confirmed that the required admission nutritional assessments by an RD had not been completed for the two residents.
Failure to Maintain Resident Weights
Penalty
Summary
The facility failed to maintain the weight of five residents, with survey observations and record review showing ongoing poor intake and significant weight loss. The deficiency was based on observation, interview, and chart review for residents 103, 48, 54, 2, and 89. The report states this failure had the potential to lead to malnutrition, muscle wasting, functional loss, and increased susceptibility to infections. Resident 103, a resident in her 60s with a right humerus fracture, DM2, retinopathy, HTN, and anemia, was observed picking at lunch and saying the food was pretty good but would be better with salt. Her weight dropped from 178 lbs to 160 lbs and then to 150 lbs within about seven weeks, with the losses described as severe. A nutrition note documented inadequate oral intake with an average 50% meal intake and a goal of comfort care focused. The RD stated she interpreted the POLST comfort measures selection to mean no weight or food intake goals were desired, while the ADON stated the POLST was not for day-to-day care planning. Resident 48, an older resident with DM2, CKD, muscle wasting, moderate protein/calorie malnutrition, osteoporosis, anemia, dementia, and dysphagia, was observed asleep through meals with trays left untouched, and at one meal she appeared confused and unable to identify how to use empty cups. She did not eat during the observed meal periods and no staff arrived to assist her over a 20-minute period. Her weight declined from 124 lbs to 92 lbs over the documented period. Nutrition notes recommended supplements, encouraged PO/fluids, and small portions, and the current care plan listed comfort care focused. The RD stated the resident had been refusing meals and only drinking supplements, was unsure what language she spoke, and had not initiated 1:1 feeding assistance. Resident 54, a resident in his 70s with CHF, DM2, dysphagia, severe protein/calorie malnutrition, anemia, and muscle wasting, stated he disliked the food because it lacked seasoning, the pureed texture was unappealing, and hot food was served cold. He said he wanted a soft scrambled egg but staff never offered a substitute, and he returned a lunch tray because the hot items were cold. His weight fell from 173 lbs to 156 lbs, then 146 lbs, and later 145 lbs. Nutrition documentation identified unintentional weight loss and noted honoring food preferences and offering meal substitutes when intake was less than 50%, but the RD stated the root cause was not clearly identified and that interventions did not address the reasons he gave for low intake. Resident 2, a resident in her 70s with dysphagia, depression, and muscle wasting, reported choking on oatmeal and difficulty swallowing pureed ham that she described as grainy and caught in her throat. She was receiving tube feedings via G-tube and had been started on pureed food for oral gratification. Her weight history showed a loss from 190 lbs to 168 lbs in one month, described as severe, with later weights fluctuating to 175 lbs and 171 lbs. The RD stated she kept a word document of recommendations but had no system to follow up whether recommendations were adopted. Resident 89, an older resident with DM2, stroke with left-sided weakness, dysphagia, and muscle weakness, stated she did not like the food and would eat better if she could have a salt packet. She reported losing weight because she disliked the food. Her weight history showed a steady decline from 200 lbs to 155 lbs over several months, including a severe loss of 9 lbs in one month. Nutrition notes described variable supplement intake and unintentional significant weight loss related to poor PO intake, while later notes added water to meals and changed the diet to CCD. The RD stated the resident had been losing weight because she did not care for the food served, and the interventions did not address that stated reason.
Failure to Follow Feeding Assistance and Swallowing Orders
Penalty
Summary
The facility failed to ensure Resident #45’s care-planned interventions were implemented and physician orders were followed for eating assistance and adaptive equipment. Resident #45 was admitted after a hospital stay with discharge diagnoses including failure to thrive, unsteady gait, and severe malnutrition, and his records also listed cerebral infarction, unspecified protein-calorie malnutrition, and adult failure to thrive. The hospital discharge instructions included a soft, bite-sized diet with thin liquids, aspiration precautions, one-to-one supervision, slow feeding, upright positioning, no straws, and medications whole in puree, but the facility’s physician orders did not include an order to give medications whole in applesauce or pudding. The record showed that Resident #45’s physician orders included assistance with all meals and no straws, and the care plan included eating assistance and no straws. Speech therapy evaluated him for dysphagia and recommended nectar-thick liquids and mechanical soft/ground textures. Therapy documentation also noted that on one occasion he had thin liquids at the bedside despite being on nectar-thick liquids, and the thin liquid was removed after staff education. The admission MDS reflected severe cognitive impairment and that he required supervision or touching assistance with eating. Survey observations showed Resident #45 eating without staff present after meal setup, including one observation where he was seated with a meal tray and no staff assisting him, and another where staff set up the meal and left the room. The DOR stated he needed supervision, a lot of cueing, small bites, alternating bites and sips, and that staff should stay in the room while he ate. Additional observations showed Resident #45 using a straw even though he was not supposed to have straws, and the DOR confirmed the straw was not allowed. An LPN confirmed that medications were given whole in applesauce even though no physician order was present for that method.
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