Failure to Follow IDDSI Level 5 Diet Order Leads to Choking Event
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for a texture‑modified diet for one resident with dysphagia-related risk, resulting in the resident being served an inappropriate regular‑texture meal. The resident had moderately impaired cognition, diagnoses including epilepsy, COPD, and right lower lobe lung cancer, and had recently been hospitalized for pneumonitis due to inhalation of food and vomit. Upon discharge from the hospital, the physician ordered an IDDSI Level 5 minced and moist diet with slightly thick liquids. The resident’s care plan and Diet Notification Form were revised on the same day to reflect a Level 5 minced and moist texture, slightly thick liquids, direct supervision in the dining room, and placement on the assisted side of the dining room, with interventions to monitor and report signs of chewing or swallowing difficulties, coughing, or choking. Despite these updated orders and care plan revisions, on the evening in question the resident was served a tuna melt sandwich on a regular hamburger bun and sweet potato tots, rather than a properly prepared minced and moist meal. The facility’s own IDDSI guidelines specified that Level 5 minced and moist foods require no biting, minimal chewing, and that no regular dry bread is allowed due to high choking risk, with food pieces not to exceed 4 mm in size. The facility’s alternate menu for Level 5 diets indicated that residents on this diet should receive minced tuna salad with minced or pureed bread, minced sweet potato puffs, and pureed dessert, not a regular bun. The cook reported that he prepared tuna melts by placing tuna with mayo and pickle relish on a hamburger bun, wrapping it in foil, baking it, and holding it in the steam table, and believed that a “soggy” bun was acceptable for a minced and moist diet. He gave the plate to a nursing assistant, who cut the sandwich in half and served it to the resident. Multiple staff interviews confirmed that the resident was served and had eaten part of a sandwich on a bun with sweet potato tots. A nursing assistant stated she handed the resident’s dietary card to the cook and received a tuna melt on a bun with sweet potato tots, and that she was unaware of the resident’s new diet change since his recent hospital return. Dietary aides described seeing the resident with a sandwich between buns and sweet potato tots on his plate, with part of the sandwich already eaten, and observed the resident making abnormal breathing noises, turning gray, and then actively choking. The resident was brought to the nurse’s station, where an LPN found him cyanotic, not breathing, non‑responsive, with food debris around his mouth and on his clothing, and performed the Heimlich maneuver multiple times before the resident began agonal breathing and was sent to the ED. ED documentation noted copious solid food removed from the resident’s mouth, large pieces of bread and cheese in the material expelled, and a chest x‑ray showing a food bolus. The DON later clarified that the LPN had not actually verified the diet texture against the physician order at the time of the incident and had relied on the cook’s statement that the meal was correct, contributing to the failure to provide the ordered minced and moist diet. The situation was determined to be an Immediate Jeopardy beginning when the resident was served the regular‑texture tuna melt on a bun and sweet potato tots, which did not meet the IDDSI Level 5 minced and moist requirements and directly conflicted with the physician’s diet order and the facility’s own diet guidelines and menus for texture‑modified diets.
Removal Plan
- Educate all staff regarding IDDSI modified texture and physician ordered diets with competencies
- Review dietary policy and procedure
- Validate resident diets
- Update care plans
- Audit all meals to assure residents on special textured diets receive the proper diet texture foods
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.