F0808

J

Failure to Follow Therapeutic Diet Orders for Residents With Dysphagia and Aspiration Risk

Detroit Lakes, Minnesota Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that therapeutic and modified diets were implemented and served in accordance with physician orders for three residents with dysphagia and high aspiration risk. One resident with dementia, dysphagia, aphasia, and a strict NPO order following a stroke was brought to the dining room after a therapy session, even though she did not normally dine there. The dining assistant, who had not used the available tablet to verify diet orders and believed the resident was someone else, served her a regular textured meal consisting of a ham or turkey sandwich with cheese and juice. The resident’s significant other observed her eating a sandwich and salad, and a staff member then stated she was not supposed to have food. The RN assessed the resident, found her SpO2 at 71%, and she was sent to the ED, where documentation indicated a transient hypoxic episode after being given lunch despite strict NPO status, with concern for an aspiration event.

Another resident with multiple sclerosis, mild cognitive impairment, and dysphagia had a physician order for a Level 4 pureed texture diet with thin liquids. Her care plan identified a regular diet with pureed meats and directed staff to serve the diet as ordered. She had a recent history of choking and regurgitation episodes, including an event where she was spitting up food, had wheezing in the lower lung lobes, and required an ED visit with EGD and extraction of a food bolus. Despite this history and the ordered pureed diet, surveyors observed her in the dining room eating a hotdish made from stuffing with chunks of turkey, which dining staff identified as appropriate for a regular or minced and moist diet, not a pureed diet. At the time of observation, dining assistants acknowledged that diet information was available on iPads and diet slips but admitted they sometimes did not use them, and no such tools were in use until prompted by the surveyor.

A third resident with dementia, expressive aphasia, and dysphagia had physician orders and a care plan for a Level 4 pureed texture diet with Level 2 mildly thick liquids. The care plan also documented that his family member could provide thin liquids and different textures only when present and that snacks left by the family for use in the resident’s absence were to be compatible with his modified diet. Progress notes documented prior concerns about pocketing food, a choking episode in the dining room where he was not breathing and had turned purple, and subsequent changes to a pureed diet and restrictions on snacks in his room. Despite these orders and documented risks, surveyors observed him independently propelling himself in his wheelchair near the dining room while eating Oreo cookies without staff supervision. The DON later confirmed there was no signed consent for a liberalized diet and that the family member did not want him to have Oreo cookies, and the facility’s own therapeutic diet policy required that snacks be compatible with the therapeutic diet.

Removal Plan

• Review the facility process for ensuring the correct resident receives the correct diet as prescribed by the provider.
• Review and revise care plans for accuracy.
• Educate all staff with competency on resident care plan revisions, the facility procedure for implementing physician-ordered diets, diet textures, and protections from negative outcomes.
• Implement meal tray audits.