Failure to Provide Physician-Ordered Dysphagia Diet Texture Resulting in Harm
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, dysphagia, and muscle weakness had a physician order for a chopped texture diet, but was served unchopped quiche and matzoh balls during a meal. The family member reported this happened often and said they had to chop the resident's food themselves, while the DON and DFD confirmed the resident should have received the correct texture and that some items were not chopped before being sent to the unit.
Failure to Follow Ordered Texture Diet: A resident with dysphagia and an ordered puree/liquified diet received sponge cake instead of the prescribed texture. The resident later developed N/V, SOB, and possible aspiration after eating non-pureed food, requiring ED evaluation via 911. The DM confirmed the wrong texture was served, and the DON/ADON acknowledged that diet orders were not followed.
A resident with a dysphagia puree diet order was served a regular consistency roll at lunch. An NA buttered the roll and gave it to the resident in the dining room until a surveyor intervened and had it removed; the NA acknowledged the resident should not have received it.
Incorrect Diet Texture Served to a Resident with Dysphagia: A resident with severe cognitive impairment, dysphagia, and malnutrition was ordered a mechanical soft diet with thin liquids, but staff served meals with incorrect textures, including whole asparagus, thick-cut bacon, and a whole hard-boiled egg. The NA said she was new and did not know the resident’s diet needs, while dietary staff said the meal tickets and food preparation were inconsistent and that some items were not prepared to the ordered texture.
A resident with severe cognitive impairment, dementia, and malnutrition did not receive diet care consistent with the ARNP’s orders. Staff failed to transcribe updated orders for honey-thick liquids and specific feeding instructions into the EMR/Kardex, the resident continued receiving a nectar-thick supplement, and staff were observed feeding and assisting the resident from the wrong side instead of the ordered right side.
Failure to Serve Ground Meatloaf for Mechanical Soft Diets: The facility did not serve ground meatloaf as listed on the menu extension sheet for residents on mechanical soft diets. During tray line service, a dietary staff member stated there was no ground meatloaf because she had been told the meatloaf was mechanical soft friendly. The DM and RD agreed with that interpretation, while the ST stated mechanical soft meats are typically ground and that the affected residents should have received ground meatloaf.
Resident on chopped diet received unchopped meal items
Penalty
Summary
The facility failed to ensure that a resident with a physician-ordered chopped texture diet received food prepared in the correct form. The resident had diagnoses including dementia, dysphagia, and muscle weakness, and care plan interventions called for diet and food consistency per physician order, along with assistance and monitoring during meals. The physician order required no concentrated sweets, chopped texture, and thin liquids, and a speech language pathologist note documented that the resident continued to tolerate a chopped diet with thin liquids. On the dinner meal in question, the resident was served a slice of quiche and matzoh balls in soup that were not chopped, despite the chopped diet order. The resident's family member stated they often had to chop the resident's food themselves and reported that the unchopped meal was shown to an LPN. The Director of Food Services confirmed the resident was on a chopped texture diet and received unchopped quiche and matzoh balls, and stated these items were not chopped before delivery to the unit because kitchen staff did not chop certain foods to preserve their structure and presentation. The DON stated nursing staff must ensure residents on mechanically altered diets received the appropriate textured food, and the LPN stated they would chop food upon request but could not recall whether they assisted with this meal.
Failure to Follow Ordered Texture Diet
Penalty
Summary
The facility failed to ensure that a resident with dysphagia received food prepared in the ordered texture. Resident 1 was admitted with multiple diagnoses, including dysphagia, and the MDS indicated difficulty swallowing and a mechanically altered diet. The resident’s OSR listed a liquified texture diet, and the care plan directed staff to follow the diet/MD order. Despite these orders, the resident received sponge cake, which was not the prescribed puree-type texture. The physician progress note documented that the resident had been sent to the ED via 911 after nausea, vomiting, and possible aspiration following ingestion of non-pureed food. The note stated the resident developed nausea/vomiting and shortness of breath after consuming pound cake with raisins despite being on a strict pureed diet due to dysphagia, and was noted to have spitting up mucus and vomiting, raising concern for aspiration. The Dietary Manager confirmed the resident received a different texture than ordered, and the ADON acknowledged that all diet orders were expected to be followed and confirmed the resident’s prescribed diet was not followed.
Inappropriate Food Texture Served to Resident on Puree Diet
Penalty
Summary
Food was not provided in a form designed to meet an individual resident’s needs when Resident #111, who had an order for a regular diet with dysphagia puree texture and thin liquids, was served a regular consistency roll at lunch. The resident’s diet order also included fortified cereal at breakfast, fortified soup at lunch and dinner, and a two-handled cup with lid for meals. During a dining room observation, Nurse Aide #64 served the resident’s lunch tray and buttered a regular roll for the resident. Before the resident ate it, the State surveyor intervened and had the nurse aide remove the roll. Nurse Aide #64 confirmed the resident was on a puree diet and should not have received a regular roll, stating, “Yeah, you’re right,” and that she did not think it looked right.
Incorrect Diet Texture Served to Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a severely cognitively impaired resident with dysphagia received the ordered mechanical soft diet texture. The resident had diagnoses including oropharyngeal phase dysphagia and moderate protein-calorie malnutrition, and the record showed she was edentulous with dentures not available during a prior hospital SLP evaluation. The SLP documented oral holding and prolonged oral transit with puree solids and thin liquids, and later recommended a mechanical soft diet with thin liquids, small bites and sips, slow rate, and supervision while eating. During observation, the resident was served meals that did not match the ordered texture. At lunch, the tray contained a whole soft dinner roll, ground turkey chili with beans over cream of rice, and whole asparagus spears; the resident attempted to eat the asparagus but was unsuccessful. At breakfast, the tray contained a large slice of thick cut bacon and a whole hard-boiled egg with only a small area of teeth indentation. The meal tickets indicated mechanical soft textures, but the foods served did not match the ordered diet texture for the resident. Interviews with nursing and dietary staff showed confusion and inconsistency in how the diet order was interpreted and prepared. The NA who delivered the trays stated she was new and did not know the resident required a mechanical soft diet or that certain foods needed to be ground or mashed. The Dietary Manager stated the facility did not offer a mechanical soft ground diet, did not know why the ticket reflected that notation, and was not aware that asparagus should have been chopped or that the hard-boiled egg needed to be mashed. The SLP, RD, DON, NP, and Administrator all stated the resident should have received the correct mechanical soft texture, and staff acknowledged that the incorrect textures were served on both observed meals.
Failure to Follow and Transcribe Ordered Therapeutic Diet
Penalty
Summary
The facility failed to serve the appropriate therapeutic diet for Resident #5 according to the resident’s diet order. Resident #5 had a BIMS score of 1, indicating severe cognitive impairment, and diagnoses including Alzheimer’s disease, non-Alzheimer’s disease, and malnutrition. The resident’s MDS documented a mechanically altered diet, and the care plan directed staff to provide the diet as ordered and monitor for signs and symptoms of aspiration or difficulty swallowing. A diet order dated 4/13/26 directed a regular diet with pureed texture and nectar-thick fluids, and a progress note dated 7/2/26 documented new physician orders and feeding instructions for honey-thick liquids, positioning on the resident’s right side, giving a drink after each bite, and continuing the pureed diet. The resident’s record was not updated to reflect the new physician orders and feeding instructions in the physician order tab or Kardex. The July 2026 MAR listed a mighty shake as nectar-thick, and the resident received the nectar-thick supplement from 7/2/26 through 7/20/26. On 7/21/26, surveyors observed thickened water with a lid and straw in the resident’s room, and the DON verified it was nectar consistency. Later that morning, Staff B provided one-on-one feeding assistance while sitting on the resident’s left side instead of the right side ordered by the ARNP, and Staff C also sat on the resident’s left side while assisting with the mighty shake. The DON acknowledged staff did not transcribe the 7/2/26 physician orders to the electronic medical record.
Failure to Serve Ground Meatloaf for Mechanical Soft Diets
Penalty
Summary
The facility failed to ensure ground meatloaf was served for residents on mechanically altered diets according to the menu extension sheet. The lunch menu for 07/22/26 listed homemade meatloaf, mashed potatoes with gravy, and California blend vegetables, and the menu extension sheet specified that the mechanical soft meatloaf should be ground using a #10 scoop with one ounce of gravy, while pureed meatloaf and vegetables had separate serving sizes. During observation of the lunch tray line, the dietary staff member plating the meals stated there was no ground meatloaf for the mechanical soft diets because she had been told the meatloaf was mechanical soft friendly. Review of the diet type report showed four residents received a mechanical soft diet and one resident received a regular diet with ground meat. The Dietary Manager and Registered Dietitian stated the meatloaf was considered mechanical soft friendly even though the menu extension indicated it should be ground for the mechanical soft diet. The Speech Therapist stated that for mechanical soft diets, meats were typically ground, that meatloaf was considered a formed food unless cut up, and that residents on a mechanical soft diet should have received ground meat. She also verified that four residents she knew needed ground meat and confirmed that the resident she did not know received a mechanical soft diet and should have received ground meatloaf per the menu extension sheet.
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