Resident Served Incorrect Diet Texture Despite Physician Order
Summary
A deficiency occurred when a resident with a physician-ordered carbohydrate controlled, soft and bite-sized (SB6) diet was served a regular texture slice of bread during a lunch meal. The resident's meal ticket indicated the correct diet order, and both the Assistant Director of Nursing (ADON) and Dietary Services Director (DSD) were observed checking the meal and diet orders prior to service. Despite these checks, the resident received food inconsistent with the prescribed diet. The facility's policy requires that therapeutic diets, including mechanically altered diets, be provided as ordered by the physician or a delegated registered or licensed dietitian, and that dietary and nursing staff ensure the correct form and content of meals. The resident in question had a history of severe cognitive impairment and had been recommended a soft and bite-sized diet by the Speech Language Pathologist (SLP). The SLP confirmed that any changes to a resident's diet are not active until a physician's order is written and entered into the electronic health record (EHR). At the time of the incident, the order had not been updated to allow regular bread, and the SLP verified that the resident should not have received it. The failure to provide the correct diet as ordered posed a risk of aspiration and unmet nutritional needs for the resident.
Plan Of Correction
F808 Therapeutic Diet Prescribed by Physician Corrective action for residents found to have been affected by this deficiency: - DS and RD in-serviced dietary staff immediately on 6/16/25 and completed for all dietary staff on 6/17/25, utilizing P&P "Therapeutic Diet Orders" ensuring that all diet textures are followed according to the physician's orders. - DS audited dinner for Resident 61 on 6/16/25, ensuring the resident's diet order was followed and the correct food items were served. Corrective action for residents that may be affected by this deficiency: - DS, RD, or trained designee will conduct tray line audits at various mealtimes, comparing resident meals with the PCC Diet Type Report, ensuring meal tray accuracy. Measures that will be put into place to ensure that this deficiency does not recur: - Licensed nurses will continue to audit meal trays with the PCC Diet Type Report at all mealtimes before meal trays are provided to the residents. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: - DS, RD, or licensed nurse will report their findings regarding diet order monitoring to the QA committee for discussion and further recommendations. The QA will continue monitoring for a minimum of 3 months or until substantial compliance is achieved. Date of compliance: 6/17/25
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with DM2, malnutrition, and no teeth did not receive the ordered controlled carbohydrate diabetic diet. The hospital discharge orders, facility admission summary, and NP notes all indicated a diabetic diet, and the niece requested an easy chew diabetic diet due to chewing difficulty. The RD, DON, and NP stated the resident should have received the ordered therapeutic diet.
Therapeutic diet orders were not followed for two residents. One resident ordered large portions but received a regular-size meal serving, and another resident ordered small carb portions with large protein portions but received a regular-size protein portion. Staff confirmed the ordered portions were not provided, despite the tray cards reflecting the prescribed diets.
A resident with HF, prediabetes, and anemia was supposed to receive double portions of protein as part of a therapeutic diet, but staff served only single portions at lunch. The resident’s care plan and tray card indicated double portions were required, and a dietary employee confirmed the resident was to receive double portions at meals.
A resident with multiple chronic conditions, including dysphagia risk, had a diet change from mechanical soft with thin liquids to pureed with nectar thick liquids after staff noted pocketing food. The record lacked a physician or RD order and did not show a comprehensive swallowing assessment or speech therapy referral tied to the downgrade. Interviews confirmed the RD was unaware of the diet change, the DOR had no therapy assessment for swallowing, and the NP believed a verbal order had been given, but no documentation supported it.
A facility failed to provide therapeutic diets as ordered for two residents. Both residents had dysphagia mechanical soft diet orders, but their tray cards indicated a pureed buttered dinner roll and they were served a regular roll instead of the ordered pureed consistency roll. The RD confirmed the mismatch, and staff checked additional dysphagia mechanical soft trays in the dining room for regular bread.
A resident with Parkinson’s disease, dysphagia, cognitive impairment, and weight loss had a physician order for a health shake with meals as part of a therapeutic diet. During meal service, the shake was not on the tray and no substitute was offered; staff said the dietary aide forgot it and the LVN missed it when checking trays, while the resident reported he sometimes receives the shake and sometimes does not.
Failure to Implement Ordered Diabetic Diet
Penalty
Summary
The facility failed to implement a physician-ordered therapeutic diet for one resident with Type II diabetes, malnutrition, and a pressure ulcer. Record review showed the resident was re-admitted on 04/30/2026 and had hospital discharge orders for a diabetic diet, with the facility admission summary also indicating a diabetic diet was to be provided. The resident’s NP progress notes on 05/02/2026, 05/07/2026, and 05/11/2026 documented a controlled carbohydrate diet. Interviews and record review showed the resident’s diet did not match the ordered therapeutic diet. The resident’s niece stated the resident had diabetes and difficulty chewing because the resident had no teeth, and she requested an easy chew diabetic diet during a care conference. The RD stated residents with diabetes should receive a consistent carbohydrate diabetic diet and residents without teeth should receive an altered texture diet appropriate for chewing difficulties, and that the resident should have been receiving a controlled carbohydrate diabetic diet as ordered. The DON and NP #1 both stated residents with diabetes or hospital orders for a diabetic diet should receive the ordered therapeutic diet, and NP #1 noted that if the diabetic diet order was not entered into the EHR, the resident could receive a regular diet.
Therapeutic Diet Orders Not Followed
Penalty
Summary
The facility failed to ensure therapeutic diets were provided as ordered by the attending physician for two residents. Resident #31 had a diet order for a regular/liberalized diet with regular texture, thin liquids, and large portions, but during observation the resident’s lunch tray card stated large portions while the resident received a regular-size serving; RN #3 confirmed the serving was regular size. The resident’s care plan identified nutrition concern related to potential for inadequate po intake and GERD. Resident #68 had a diet order for a consistent carbohydrate diet with regular texture, thin liquids, small carb portions, large protein portions, and fruit instead of dessert, but during lunch observation the tray card stated large protein and the resident was served a regular-size portion of protein; Nurse Aide #30 confirmed the resident did not receive a large portion of protein.
Therapeutic Diet Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that a therapeutic diet was provided as recommended by a registered dietitian for one resident who had diagnoses including heart failure, prediabetes, and anemia. The resident’s MDS indicated he was alert and oriented and was on a therapeutic diet. A nutrition note documented that he requested double portions of protein, and the care plan identified a potential for nutritional problems related to anemia with an intervention for staff to provide a double portion of protein. On the day of observation, the resident was seen in his room with his lunch tray, and the tray card indicated he was to receive double portions of food at meals; however, he only received one portion of each lunch item, including ham, cabbage, and a sweet potato. The resident stated he had a good appetite and was not happy that he did not receive a double portion of food. A dietary employee later confirmed that the resident was supposed to receive double portions at meals.
Unapproved Diet Downgrade Without Assessment
Penalty
Summary
The facility did not ensure a resident’s change in diet consistency was comprehensively assessed or supported by physician or Registered Dietitian documentation after a change in condition. R14, who had diagnoses including metabolic encephalopathy, seizures, senile dementia, COPD, asthma, AKI, anemia, bipolar type 2, paranoid schizophrenia, anxiety, depression, dehydration, and bacteriuria, was documented on care plans and MDS assessments as needing set-up assistance for eating and being on a mechanically altered diet due to dysphagia. The nutrition care plan also identified risks related to obesity, fluid shifts, and impaired skin integrity, and nursing documentation showed physician orders to monitor for pocketing food every shift. On 12/23/25, an LPN documented that R14 was pocketing food and that the diet was downgraded to pureed with nectar liquids. However, there was no documentation that a swallowing assessment or other comprehensive assessment was completed for the diet change, and there was no physician order or RD order supporting the downgrade. The dietary department later had a Diet Change Form for pureed consistency and nectar thick liquids, but the record did not show an order authorizing the change. During interviews, the RD stated she completed a nutritional assessment and was not aware of eating concerns or diet changes for R14. The DOR stated R14 had not received therapy services since 10/2/25 and had no referral or assessment for speech therapy related to swallowing changes. The NP later documented that R14 had significant swallowing difficulties and that the diet was downgraded, but the surveyor noted the record still lacked documentation of an order or swallowing assessment for the consistency change.
Therapeutic Diet Orders Not Followed for Two Residents
Penalty
Summary
The facility failed to ensure therapeutic diets were provided as ordered by the attending physician for Resident #5 and Resident #35. Resident #5 had an order for a regular diet with dysphagia mechanical soft texture and nectar-thickened liquids, but the tray card stated Dys Mech - Regular and Pureed Buttered Dinner Roll - #16 Scp, and the resident was served a whole, unbuttered roll with the lunch meal. Resident #35 had an order for a regular diet with dysphagia mechanical soft texture and thin liquids, and the tray card also stated Dys Mech - Regular and Pureed Bettered Dinner Roll - #16 Scp. At 12:10 PM, the Registered Dietician confirmed that both residents' tray cards indicated a dysphagia mechanical soft diet with a pureed buttered dinner roll, but the residents did not receive a pureed consistency roll and instead received a regular roll. The residents did not consume their whole rolls secondary to surveyor intervention, and staff checked additional dysphagia mechanical soft trays in the dining room for regular consistency bread.
Therapeutic Diet Supplement Not Provided as Ordered
Penalty
Summary
The facility failed to ensure a therapeutic diet order was carried out for one resident who had Parkinson’s disease, dysphagia, moderate cognitive impairment, dependence for all eating, and documented weight loss. The resident’s record showed a physician order for a health shake with meals as part of a therapeutic diet plan for nutritional support, along with a mechanically altered diet and nectar consistency. The care plan addressed actual weight loss related to diet change and decreased oral intake, with an intervention for diet as ordered. During meal service observation, the resident did not receive the ordered health shake with the lunch tray, and no substitute supplement was offered or provided at that time even though the meal ticket listed the shake. The resident stated he had not received the shake and said he sometimes gets it and sometimes does not. Staff interviews showed the CNA was unaware the shake had not been delivered, the dietary aide said she forgot to put it on the tray, the LVN stated she must have missed it when checking the tray, and the dietary manager said the order was supposed to be followed from the meal tickets. The DON and Administrator both stated the resident was expected to receive the health shake with meals.
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