F0805

J

Failure to Provide Physician-Ordered Dysphagia Diet Texture Resulting in Harm

Colorado Springs, Colorado Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident received food in the correct texture as ordered by the physician. The resident was admitted with multiple significant diagnoses, including Barrett’s esophagus, Zenker’s diverticulum, dysphagia, GERD, dementia, and a recent history of pneumonia and acute respiratory failure. Hospital records prior to admission documented ongoing oral and suspected pharyngeal dysphagia with overt signs of laryngeal penetration and aspiration on thin liquids and regular solids, and the hospital SLP recommended a dysphagia level 6 (soft and bite-sized) diet with thin liquids, along with specific swallowing precautions. The hospital discharge summary documented that the resident was discharged on a dysphagia diet due to dysphagia being the discharging diagnosis.

Upon admission, the facility did not transcribe the physician-ordered dysphagia level 6 diet into the resident’s medical record and did not complete or transmit the required diet form from nursing to dietary. The baseline care plan instead documented a regular texture diet with thin liquids and instructions for the resident to eat two bites and then drink water, which conflicted with the hospital discharge documentation and SLP recommendations. There was no physician order for diet texture in the facility record, indicating the ordered dysphagia diet was not entered. The DON later confirmed that the admitting nurse did not verify and transcribe the diet order and that the nursing department did not complete the diet form needed to communicate the diet to dietary.

As a result of these omissions, the resident was served regular texture meals rather than the ordered dysphagia level 6 soft and bite-sized diet. The dietary manager reported that, from admission until after breakfast the following day, the resident received regular texture meals, including pork loin for dinner and eggs with sausage links for breakfast, with the meat only cut up but not altered to a soft, fork-depressible consistency. After the diet order was eventually communicated to dietary, the resident was still served an egg salad sandwich on whole bread with crust and a bag of potato chips for dinner, which did not meet IDDSI level 6 criteria and was not considered appropriate for the resident based on the hospital records and SLP interview. The resident’s representative observed the resident consuming this boxed meal and later reported that the resident appeared to have worsened, with coughing, pain on swallowing, and difficulty breathing, leading to transfer back to the hospital, where an upper GI endoscopy revealed a bleeding Zenker’s diverticulum with a large opening and impacted food requiring surgical removal.

Staff interviews further described the breakdown in processes that led to the deficiency. The RD explained that the usual process required nursing to complete a diet form for new admissions and provide it to dietary so the diet could be entered into the tray ticket system, but this was not done for this resident. The dietary manager confirmed that no formal diet form was received, that a text message thread used on the admission day was not a formal communication system, and that she assumed certain items, such as an egg salad sandwich and thin potato chips, were dysphagia-appropriate. The SLP clarified that dysphagia level 6 soft and bite-sized foods must be chopped into 1.5 cm pieces, be soft enough to be fully flattened with a fork, and that regular texture meats, whole bread with crust, and potato chips were not appropriate for this resident given his diagnoses and swallowing difficulties. The DON acknowledged that the facility did not follow its established admission and diet communication processes and confirmed that the resident should have been provided a dysphagia level 6 soft and bite-sized diet upon admission but instead received regular texture meals and later an inappropriate sandwich and chips.

Removal Plan

• The facility conducted an audit to identify other residents who may be receiving the incorrect diet texture by reviewing physician orders and dietary tickets; no other issues were identified.
• The DON or designee provided education to all nursing and dining staff on therapeutic (mechanically altered) diets, the admission process for diet order transcription to the medical record, communication of diet to the dietary department, and accurate documentation in the baseline care plan; staff will not be permitted to work until trained.
• The SLP provided education to dietary staff on therapeutic (mechanically altered) diet textures per IDDSI guidelines; education will continue until all dietary staff have been educated prior to working.
• The DON provided education to nursing staff on how to read the resident's tray card and properly identify correct altered textured diets; education will continue until all staff are sufficiently trained.
• All new staff will receive the same training prior to working in the kitchen or serving residents food, snacks, or beverages.
• The DON reviewed all identified residents with altered diet texture care plans and updated them to reflect each resident's specific dietary interventions and needs.