Failure to Follow IDDSI Level 5 Diet Order Leads to Choking Event
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
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Pureed diet foods were not consistently prepared to the required pudding-like consistency for two residents with dysphagia diets. During meal observation and a test tray review, the SLP and Dietary leadership found that some pureed items were smooth, but others, including a dessert item, were thick and sticky like peanut butter and did not slide off the spoon. The SLP, RD, District Dietary Manager, and Administrator all acknowledged ongoing inconsistency in pureed food preparation, with staff turnover and lack of a standard recipe contributing to the issue.
Failure to Serve Ordered Thickened Liquids: A resident with dysphasia and an order for honey-thick liquids was served thin tomato soup during lunch, even though staff had prepared his tea with thickener. The SLP note documented the resident tolerated thin liquids without overt s/s of aspiration during an assessment, but interviews confirmed nursing staff were responsible for thickening soups and drinks before service and that the soup should have been thickened to honey consistency.
A resident with severe cognitive impairment and a physician-ordered puree diabetic diet was given a peanut butter and jelly uncrustable during a snack pass after asking for more food. Staff later stated they did not know the item was not appropriate for a puree diet and that diet lists were not available to them at the time. The resident choked, became unresponsive, lost her pulse, and required CPR and EMS intervention; hospital records noted a small pneumothorax and rib fractures related to CPR.
A resident with dysphagia and a chopped meat diet order choked after being served a large piece of chicken that was not prepared to the ordered texture. Staff attempted the Heimlich maneuver, back blows, and CPR before EMS removed the chicken from the airway. The resident was hospitalized in critical condition, later required intubation and a G-tube, and speech therapy recommended NPO.
Improper Preparation of IDDSI Level 5 Minced and Moist Meal: A resident’s MM5 meal was prepared at the tray line using SB6 chopped meat instead of food minced in advance to the required size. A dietary staff member mashed the meat with a scoop and added gravy, and the DS stated the meat pieces were too large and that preparing MM5 during plating was not appropriate. The facility recipe required the food to be processed to 4 x 15 mm, and the therapeutic diet policy called for diets to be planned and prepared with the Dietitian.
A resident who required a pureed diet was served a lunch entree with visible lumps, and the CNA confirmed the puree was lumpy. The ST stated the resident needed a pureed consistency and that pureed foods should be smooth with no lumps or bumps. The report also identified six additional residents receiving pureed texture who could have been affected.
Pureed Diet Foods Served at Incorrect Consistency
Penalty
Summary
The facility failed to serve pureed food items in the applesauce- or pudding-like consistency required for residents with advanced dysphagia diets. During lunch meal observation, the SLP reported that residents ordered pureed diets could not eat the food because it was too thick to swallow, describing the pureed items from the kitchen as paste-like rather than the expected applesauce-like consistency. She stated that when she observed pureed food that was too thick, she returned it to the kitchen so dietary staff could add more liquid, and she attributed the inconsistency to high dietary staff turnover and inadequate training. A test tray reviewed with the District Dietary Manager showed that the pureed chicken, collard greens, mashed potatoes, and bread were smooth and pudding-like, but the pureed brownie was thick and sticky, similar to peanut butter, and could not be shaken off the spoon. The District Dietary Manager agreed the brownie was too thick and said it needed more milk to reach the correct consistency. The SLP, RD, District Dietary Manager, and Administrator all acknowledged ongoing inconsistency in pureed food preparation, with the SLP stating that for the past year the food was often paste- or peanut butter-like and the District Dietary Manager noting there was no recipe for pureeing the items, making consistency difficult to maintain.
Failure to Serve Ordered Thickened Liquids
Penalty
Summary
The facility failed to ensure Resident #42 received food prepared in the ordered form for a thickened liquid diet. Resident #42 was a male resident admitted with a diagnosis of dysphasia, had a BIMS score of 14 indicating intact cognition, and required assistance with ADLs. His care plan identified a therapeutic diet related to dysphagia, and a physician order dated 07/06/2026 specified a regular diet with soft mechanical texture and honey thick consistency. During lunch observation on 07/06/2026, LVN D prepared tea with premixed thickener, but the tomato soup served to Resident #42 was not thickened and remained thin when observed dripping off the spoon in small droplets. The SLP note from the same day documented that the resident consumed thin liquids via cup without overt signs or symptoms of aspiration during a diet assessment, and the note stated he should continue meals in the dining room with staff assistance. Interviews with the Dietary Manager, SLP, LVN D, ADON, DON, and Administrator confirmed that nursing staff were responsible for thickening liquids and that the soup should have been thickened to honey consistency before serving.
Improper Texture Food Served to Resident on Puree Diet
Penalty
Summary
The facility failed to provide a resident with food prepared in a form designed to meet her individual needs and according to her physician-ordered puree diet. The resident had severe cognitive impairment, was dependent on staff for eating, and had diagnoses including schizophrenia, diabetes mellitus, and stroke. Her care plan and electronic health record documented a puree diabetic diet with regular liquids and supervision/cueing with meals, along with monitoring for chewing difficulty, pocketing, and slow eating. During an evening snack pass, staff gave the resident ice cream and then, after she said she was still hungry, provided a peanut butter and jelly uncrustable sandwich. Staff later stated the resident requested the sandwich and that they did not know it was not appropriate for a puree diet. Staff also stated there were no diet lists posted for staff to look at until after the incident, and one staff member said she was not sure what foods would be considered pureed. The resident was sitting upright in the commons area when she began choking, and staff observed wheezing, stridor, and the universal sign for choking. Staff attempted the Heimlich maneuver and back thrusts without success. The resident became pale, lost consciousness, and had no palpable pulse. CPR was started, oxygen was applied, and 911 was called. EMS later suctioned peanut butter from the resident's posterior pharynx. Hospital records documented that she had a choking episode while eating at the facility, required resuscitation, and was found to have a small pneumothorax and rib fractures related to CPR. The facility's investigation confirmed that the resident had been given a peanut butter and jelly sandwich despite being ordered a puree diet.
Choking After Receiving Food Not Prepared to Ordered Texture
Penalty
Summary
The facility failed to ensure that a resident with a physician-ordered chopped meat diet received food prepared in the ordered texture. The resident had diagnoses including Parkinson’s disease, dementia, schizoaffective disorder, chronic kidney disease, heart failure, diabetes, and oropharyngeal dysphagia. The resident’s care plan and nutrition documentation showed the resident required supervision with eating and was ordered a mechanically altered diet with chopped meats, thin liquids, and other dietary restrictions. During the dinner meal in the dining room, the resident was under CNA supervision when the resident began choking after consuming a large piece of chicken that was not prepared according to the ordered chopped meat texture. Staff attempted the Heimlich maneuver and back blows, but the resident became unresponsive. Staff then moved the resident, initiated CPR, and called 911. EMS later removed a large piece of chicken from the resident’s trachea during airway management. Witness statements and interviews indicated the resident had a whole piece of chicken on the tray after the incident, while the ordered diet required chopped meat pieces no larger than one-half inch. The resident was transported to the hospital in critical condition with choking, hypoxemia, and unresponsiveness. Hospital records showed the resident required intubation, remained unresponsive, and later required a G-tube placement. Speech therapy evaluations later recommended the resident remain NPO. The report also noted that the facility had other residents on mechanically altered diets, and that the meal ticket for this resident did not identify the dinner selection or what meal was actually served.
Improper Preparation of IDDSI Level 5 Minced and Moist Meal
Penalty
Summary
The facility failed to prepare food in accordance with the IDDSI framework for a resident who required Level 5 minced and moist foods. During lunch tray line service in the kitchen, a staff member used a scoop utensil designated for Level 6 small-and-bite-sized foods to plate chopped Salisbury Steak from the steam table for a tray that called for MM5 texture. The staff member then used the edge of the scoop utensil to mash some of the meat and stated during interview that the SB6 texture was used to create MM5 because it was soft and gravy was added. The Regional Dietary Supervisor reviewed an MM5 tray prepared for lunch and stated that the meat was too large and posed a risk of choking to residents. The supervisor also stated that preparing MM5 texture during plating was not appropriate and that texture-modified food should have been prepared in advance. The facility’s recipe for Salisbury Steak with Onions directed that IDDSI #5/minced and moist food be placed into a food processor and minced until the food was 4 x 15 mm, and the facility’s Therapeutic Diets policy stated that therapeutic diets were to be planned and prepared in consultation with the Dietitian.
Pureed Diet Served With Visible Lumps
Penalty
Summary
The facility failed to serve mechanically altered foods at an appropriate texture for a resident who required a pureed diet. Resident #24 had diagnoses including Alzheimer's disease, depression, hypertension, and COPD, and the record showed dysphagia with recommendations for puree consistency. The resident's care plan and MDS indicated severe cognitive impairment, dependence for eating, and a mechanically altered diet. During a lunch observation, the resident's pureed meat entree was plated and later served with visible lumps throughout it, and the CNA feeding the resident confirmed that the puree was lumpy. The CNA stated that pureed foods were not always completely smooth and that the consistency depended on what food items were pureed. The speech therapist stated the resident required a pureed diet because of decline and that a mechanical soft or ground meat texture would not be appropriate. The therapist also stated pureed foods should not have visible lumps or bumps and should be smooth. The report further identified six additional residents receiving pureed texture who could have been affected by the same issue.
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