Failure to Follow Therapeutic Diet Order Results in Fatal Choking Incident
Summary
A facility failed to ensure that a resident received a therapeutic diet as ordered by the physician, resulting in a fatal choking incident. The resident, who had a history of cerebrovascular disease, anoxic brain damage, dementia, dysphagia, and other significant medical conditions, was prescribed a pureed diet with nectar-thickened liquids due to severe swallowing difficulties. Despite these orders, a Certified Nurse Assistant (CNA) provided the resident with a peanut butter sandwich, which was not permitted on the prescribed diet. The CNA was aware of the resident's dietary restrictions but gave the sandwich at the resident's request, having previously observed the resident eat similar food without apparent difficulty. The incident occurred when the resident began eating the peanut butter sandwich and subsequently choked, leading to a loss of pulse. Staff attempted the Heimlich maneuver and initiated CPR, but the resident was ultimately transferred to a hospital and expired. The official cause of death was listed as choking on a food bolus. Interviews with staff confirmed that the CNA did not verify the resident's current diet order through available resources such as the KARDEX, care plan, or by consulting a nurse, despite being aware of the resident's dietary restrictions and the facility's protocols for verifying diet orders before providing snacks. Further review revealed that the facility's policies required snacks to be compatible with therapeutic diets and that staff were trained to check diet orders before providing food to residents. However, there was no specific policy or standard provided regarding acceptable food items for different therapeutic diets. The resident had a documented history of swallowing disorders and previous choking incidents, including a prior event involving a peanut butter sandwich that led to a change in diet orders and additional speech therapy interventions. Despite these measures, the failure to follow the prescribed diet directly resulted in the resident's death.
Removal Plan
- All mechanical soft and pureed snacks in the snack room and refrigerator were labeled by the Dietary Manager with the appropriate consistency.
- The Administrator reviewed all snacks and supplemental foods available outside of meal service to ensure compliance with current diet orders.
- Education was initiated by the Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator for all licensed nurses, certified medication technicians, and certified nurse aides.
- Staff were instructed on the new process for labeled snacks, the requirement to verify diet orders through the Kardex, care plan, or physicians' order, and the inappropriateness of peanut butter on a pureed diet unless blended to proper consistency under IDDSI standards.
- All staff completed return demonstrations prior to working their next scheduled shifts, and competency validation was confirmed.
- A 100% audit of all resident diet orders and Kardex entries was completed by the DON, MDS nurse, and Regional Nurse.
- The ADON completed a 100% audit of all physician diet orders in Point-Click-Care against tray tickets to ensure accuracy.
- Ongoing monitoring was implemented, including nursing audits of 10 trays per week for four weeks, followed by 10 trays monthly for three months.
- The Administrator audited snacks three times per week for four weeks, then decreased frequency over the following two months.
- All new hires will receive training on therapeutic diets, Kardex review, and snack verification during orientation prior to assuming care responsibilities.
- The QAPI Committee held an ad hoc meeting to review corrective actions, with a monthly follow-up scheduled for three months.
- The Medical Director was notified of all corrective measures and ongoing monitoring efforts and agreed with the plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Menu portions were not served with measured scoops, and the kitchen did not provide foods listed on the menu for two sampled lunch periods. A Dietary Mgr was observed using unmeasured slotted spoons for rice, snap peas, and carrots, serving a different dessert than listed, and not preparing altered-texture rice for residents on soft and bite size, minced, and pureed diets; mashed potatoes were served instead. The facility also used white bread in place of hamburger buns for two cheeseburgers.
Failure to Serve Full Portions of Altered Diets: Surveyors found the facility did not follow the menu or serve complete portion sizes for altered-texture meals. Residents on pureed and mechanical soft diets, including residents with dx such as dementia, dysphagia, malnutrition, GERD, and CVA history, were served partial scoops of entrées and sides instead of the full menu portions listed. The Administrator stated the menu should be followed and full scoops of mechanically altered diets should be served.
Failure to follow planned menu portions and diet extensions led to under-portioned meals for multiple residents. During tray line observation, a dietary aide served fish that weighed less than the ordered 3 oz portion, pudding was portioned with a smaller scoop than required, and ham portions also fell short of the recipe amount. Residents and staff reported the servings were too small, and the RD stated the kitchen should follow the menu spreadsheets and standardized recipes to ensure adequate calories and protein.
Incorrect menu portions were served during lunch meal service when staff did not follow the written menu for several residents on puree, soft and bite sized, and renal diets. A food service worker used the wrong scoop sizes for cauliflower and oven browned potatoes, and residents received portions that did not match the menu. The RD stated staff were expected to follow menus and portion sizes, and the facility policy required menu items to be prepared according to the written menus.
Staff did not follow the posted lunch menu for a puree entree and fruit side. A Dietary Manager used a #12 scoop for Puree Beef Stroganoff and stated the puree version did not include noodles, even though the recipe called for the dish to be served over rice or noodles and the diet guide listed a 6 oz portion. Staff also used a #16 scoop for Sliced Strawberries instead of the 1/2 cup portion listed on the diet guide. The RD confirmed the menu was not being followed and that the portions served were incorrect.
A facility failed to follow posted menus and tray cards for multiple residents’ meals. Several residents received chocolate ice cream or other desserts that did not match the posted menu or the tray card, and staff confirmed the mismatches during observation and interview.
Menu Portions and Food Service Did Not Match Planned Menu
Penalty
Summary
The facility failed to use measured spoons when serving food and failed to provide foods listed on the menu for 2 of 2 sampled days reviewed in the kitchen. On 06/17/2026, Staff M, Dietary Manager, was observed serving rice with a gray handled scoop, vegetable medley with a green handled scoop, and carrots, listed as an alternate to the vegetable medley, with an unmeasured silver slotted spoon. The menu for lunch that day listed a half cup of vegetable medley and a half cup of rice, but did not include carrots as an alternate. The menu also listed chocolate cake with peanut butter for dessert, but at 12:29 PM the facility served cinnamon apples instead. At 12:32 PM, there was no rice prepared for residents on soft and bite size, minced, and pureed diets. On 06/22/2026, the lunch menu listed teriyaki pot roast, snap peas, steamed rice, a dinner roll, and peach short cake, but the rice and snap peas were observed being served with unmeasured silver slotted spoons. Staff M stated the unmeasured spoons were being used to serve rice and snap peas, and that no altered texture rice was prepared, with mashed potatoes being served instead. The facility also prepared two cheeseburgers using slices of white bread in place of hamburger buns. Staff M stated the facility did not follow the menu when it specified altered textured rice and instead provided mashed potatoes, and the Administrator stated the observations of staff using unmeasured or incorrect measured spoons did not meet expectations.
Failure to Serve Full Portions of Altered Diet Menus
Penalty
Summary
The facility failed to follow the menu and serve the complete serving size of altered diet textures for 5 of 5 residents reviewed for serving sizes in a sample of 40. Surveyors observed that the diet spreadsheet for day 9 lunch listed full portions for pureed country fried steak, mashed potatoes with thick gravy, pureed seasoned pasta, pureed buttered soft bread, and pureed mandarin oranges for the pureed diet, and separate full portions for the dental soft diet. The diet spreadsheet for day 12 lunch similarly listed full portions for pureed panko mustard chicken, pureed scalloped potatoes, pureed pickled beets, pureed buttered bread, and pureed peach parfait, with separate full portions for the dental soft diet. R34 had diagnoses including bronchopneumonia, Alzheimer's disease, peripheral vascular disease, and severe protein calorie malnutrition, and had an active order for a regular diet with pureed texture, regular liquid consistency, fortified pudding at lunch and supper, whole milk with meals, and ice cream at lunch and supper. On 05/18/26 at approximately 12:20 PM, R34 received approximately 0.5 of a #8 scoop of pureed country fried steak, and on 05/21/26 at approximately 12:22 PM, received approximately 0.66 of a #6 scoop of pureed panko mustard chicken. R64, with diagnoses including GERD and a history of TIA and cerebral infarction, had an active order for a regular diet with pureed texture and regular liquid consistency, and received approximately 0.5 of a #8 scoop of pureed country fried steak and mashed potatoes on 05/18/26, and approximately 0.66 of a #6 scoop of pureed panko mustard chicken and approximately 0.66 of a #8 scoop of pureed scalloped potatoes on 05/21/26. R87 had diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage, aphasia, dementia, abnormal weight loss, and dysphagia, and had an active order for a regular diet with pureed texture, regular liquid consistency, 2x protein at breakfast, and whole milk in place of menu milk. On 05/18/26, R87 received approximately 0.5 of a #8 scoop of pureed country fried steak and mashed potatoes, and on 05/21/26 received approximately 0.66 of a #6 scoop of pureed panko mustard chicken and approximately 0.66 of a #8 scoop of pureed scalloped potatoes. R9 and R18, both ordered mechanical soft diets, also received approximately 0.5 of a #8 scoop of ground country fried steak and mashed potatoes on 05/18/26 and approximately 0.66 of a #8 scoop of ground panko mustard chicken and scalloped potatoes on 05/21/26. On 05/21/26 at 3:10 PM, the Administrator stated the menu should be followed and full scoops of the mechanically altered diets should be served.
Failure to Follow Menu Portion Sizes
Penalty
Summary
The facility failed to follow planned menus and diet extensions for lunch meal service, including the prescribed portion sizes for baked fish, baked ham, and pudding. The report states that the kitchen policies required standardized recipes, portion control, and menus to be planned in advance and followed as written, and the diet spreadsheets specified 3-ounce portions of fish and ham, along with designated scoop sizes for pudding based on diet order. The deficiency affected the facility’s food service operations for residents receiving meals prepared in the kitchen. During observation of the lunch tray line, the cook stated the baked fish portion should be 3 ounces for regular and mechanical soft diets and that pudding portions should be served using a #8 scoop for most diets and a #16 scoop for diabetic diets. However, the dietary aide was observed placing one small piece of fish on resident trays, and when the piece was weighed it measured 1.5 ounces. The largest piece selected from the cooked fish pan weighed 2 ounces. The food service manager stated the portion should have been 3 ounces and explained that the fish was purchased as a 3-ounce fillet but lost volume during cooking, noting that larger raw portions would have been needed to yield the required serving size. Residents and staff reported that the portions were too small. One resident stated the fish portion was too small and the pudding looked like only one spoonful. Other residents stated they would have liked bigger portions and that the kitchen was not giving enough food. On the next day, the ham portions were also observed to be short of the required amount: four half-slices weighed 2.2 ounces, five half-slices weighed 2.5 ounces, and six half-slices weighed 3.1 ounces. The dietary staff stated they had not been told to weigh the sliced meat to determine the correct portion, and one dietary aide stated he used a smaller scoop for pudding because he did not want to run out of food. The registered dietitian stated the kitchen should follow the menus and diet spreadsheets so residents receive adequate calories and protein, and that no one can determine ounces by eyeballing food.
Incorrect Menu Portions Served During Lunch Meal Service
Penalty
Summary
Menus were not followed during the lunch meal service when staff served incorrect portion sizes for multiple residents on therapeutic diets. During observation in the dining room, pans in the steam table contained pork chops with sauteed onions, oven browned potatoes with a #8 scoop, green peas with a #8 scoop, and steamed cauliflower with a #12 scoop. The lunch menu for the regular and puree diets specified smothered pork chop, #8 scoop oven browned potatoes, and #8 scoop seasoned green peas, while the liberalized renal diet specified smothered pork chop, #12 scoop oven browned potatoes, and #8 scoop seasoned green peas. Staff served puree cauliflower, potatoes, and pork to residents on puree diets, and one resident on a soft and bite sized diet received a #12 scoop of cauliflower instead of the expected #8 scoop portion. Four residents on liberalized renal diets received #8 scoop oven browned potatoes instead of the #12 scoop portion listed on the menu. During interview after lunch service, the food service worker confirmed using the #12 scoop for cauliflower and the #8 scoop for oven browned potatoes, and acknowledged the incorrect scoop sizes were used for cauliflower and potatoes. The registered dietitian stated staff were expected to follow menus and portion sizes and that menus needed to be available near lunch meal service for reference. The facility policy titled Food Preparation Guidelines stated the cook shall prepare menu items following the facility's written menus.
Menu Portions Not Followed for Puree Entree and Fruit Side
Penalty
Summary
The facility failed to follow the Spring/Summer 2026 Week 3 menu for Wednesday lunch by not providing the portion sizes listed for Puree Beef Stroganoff and Sliced Strawberries. The facility’s policies stated that menus should meet residents’ nutritional needs, be prepared in advance, be followed, and include portions stated in ounces or measurements. The Puree Foods policy also stated that pureed food items should be the same as those served on the regular menu, and the Food Preparation Guidelines required menu items to be prepared according to written menus and recipes. During the lunch trayline observation, the Dietary Manager was acting as the AM dietary lead. Puree Beef Stroganoff was portioned using a #12 scoop, which measured 2 2/3 oz, and a normal puree plate was observed containing one #12 scoop of Puree Beef Stroganoff, one #8 scoop of Puree beans, and one #12 scoop of Puree bread. The facility’s Beef Stroganoff recipe directed that the dish be served over rice or noodles, but the Dietary Manager stated the puree Beef Stroganoff was only the beef and gravy and did not include noodles. The Production Sheet used by staff did not include puree diet portion information. Sliced Strawberries were also portioned incorrectly. The diet guide specified 1/2 cup for the regular menu, but staff used a #16 scoop, which measured 2 oz, to serve the strawberries. The AM Dietary Aide said she used the diet guide and had not referred to the scoop chart, and she did not know the scoop size until it was pointed out. The Regional Dietary Consultant, a Registered Dietitian, stated that the correct serving for puree Beef Stroganoff should have been 6 oz of meat and gravy mixed with pasta using a #5 scoop, and that a #8 scoop should have been used for the 1/2 cup strawberries. The consultant stated the menu was not being followed and that four residents were receiving a puree diet and 75 residents were eligible to receive the strawberries.
Menu and Tray Card Mismatches
Penalty
Summary
Menus were not followed as posted and as stated on resident tray cards. The facility’s posted menu for 05/17/26 listed roasted turkey with gravy, carrots, oven browned potatoes, dinner roll or egg and sausage casserole, toast with butter and jelly, and vanilla ice cream, but tray cards observed varied and included vanilla ice cream, mixed fruit, and peanut butter pie for dessert. The Week at a Glance menu provided to the state surveyor for a Regular Liberalized diet stated vanilla ice cream, while the Therapeutic Lifestyle Change menu stated fruit sherbet. The facility policy for Menu Standards stated that daily menus would be posted and that the Week-at-a-Glance menu may be used when state regulations require portion size or posting of the entire week. During observation and staff interviews, several residents received desserts that did not match the posted menu or their tray cards. Resident #31 received chocolate ice cream even though the tray card stated peanut butter pie, and RN #3 confirmed the tray card and the dessert served. Resident #67 received chocolate ice cream and reported liking strawberry ice cream; Nurse Aide #42 confirmed the tray card stated peanut butter pie but the resident received chocolate ice cream. Resident #68 received chocolate ice cream, and Nurse Aide #30 confirmed the resident did not receive vanilla ice cream as posted; the tray card stated mixed fruit cup, but the resident received peaches and chocolate ice cream. Resident #17 received chocolate ice cream even though the tray card stated vanilla ice cream, and Nurse Aide #42 confirmed the mismatch. Resident #27 also received chocolate ice cream for dessert despite the tray card stating peanut butter pie, and Nurse Aide #23 confirmed the dessert served.
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