Failure to Provide Ordered Dysphagia Diet Textures Resulting in Choking Event and Ongoing Meal Service Errors
Summary
The deficiency involves the facility’s failure to provide physician‑ordered modified diet textures to multiple residents with dysphagia. One resident with diagnoses including oropharyngeal dysphagia, cerebral infarction, cognitive communication deficit, and unspecified dementia had a physician’s order for a Level 5 minced and moist diet and required supervision and hands‑on assistance for meals. Despite this, the resident was served a regular‑texture soft taco on a whole tortilla instead of the ordered minced and moist texture. During this meal, the resident began choking on a piece of tortilla that became stuck in the throat. A nurse attempted the Heimlich maneuver several times without dislodging the tortilla; the resident was moving air and eventually coughed up the tortilla and then required supplemental oxygen by mask. Two additional residents with dysphagia and cognitive deficits were also not provided with the correct modified diet textures. One resident, with oropharyngeal dysphagia, hemiplegia and hemiparesis following cerebrovascular disease, and cognitive communication deficit, had a physician’s order for a Level 6 soft and bite‑sized diet. Observation of a dinner meal service showed this resident received a regular‑texture hamburger on a bun with a whole lettuce leaf and a whole cookie, despite the soft and bite‑sized order. Another resident, with diagnoses including GERD, oral‑phase dysphagia, and cognitive communication deficit, had a physician’s order for a Level 6 soft and bite‑sized diet, with documentation that this resident could have regular sandwiches and hamburgers. However, this resident was observed receiving a whole cookie, which was not consistent with the ordered soft and bite‑sized texture. Staff interviews and documentation revealed gaps in understanding and implementation of diet textures and meal ticket verification. Nursing staff and CNAs reported receiving some training on diet textures, but one CNA believed that residents on soft and bite‑sized diets could have bread and possibly cookies depending on softness, which conflicted with IDDSI guidance cited in the report. The dietary manager stated he was new to the position, had been unaware of dietary extensions prior to the choking incident, and was unsure whether dietary staff had been educated on diet textures and extensions. The registered dietitian confirmed that diet tickets were generated from the EMR and included diet orders, extensions, and specific foods, and acknowledged that the residents on soft and bite‑sized diets should not have received hamburger buns, lettuce, or cookies. The administrator later attributed one instance of incorrect items (whole cookies) on tickets to a computer program glitch, while the DON acknowledged that only limited meal audits had been occurring and that the number of residents included in those audits was insufficient. The report states that the facility’s failure to ensure residents received the physician‑ordered diet textures placed residents at risk for serious harm or death if not corrected immediately. The report also notes that, at the time of the choking incident, the nurse assigned to the secured unit where the choking resident resided was not on the unit, and another RN responded to perform the Heimlich maneuver. The event note for the choking incident identified risk factors and root causes including the resident’s dysphagia, cognitive decline, poor safety awareness, and the fact that the resident was served a regular‑texture meal including a whole tortilla despite an order for minced and moist texture. The note documented that the resident lacked insight into safety regarding food intake and that the preventative measure in place prior to the incident was simply confirming the minced and moist order. Subsequent observations during survey showed that, even after this choking event, residents with ordered soft and bite‑sized diets continued to receive regular‑texture items such as whole cookies, hamburger buns, and lettuce leaves, demonstrating ongoing failure to consistently match plated meals to physician‑ordered diet textures.
Removal Plan
- Re-educate all staff involved in meal preparation or service (IDT, nursing, dietary, activities) on diet modifications and following physician orders using IDDSI standards prior to their next scheduled shift, including a post-test to demonstrate understanding; provide this education to all new IDT/nursing/dietary/activities staff during orientation; education provided by the DON or designee.
- Re-educate all dietary staff on food preparation utilizing diet extensions and recipes to adhere to each resident's diet order prior to their next scheduled shift; provide this education to all new dietary staff during orientation.
- Have the registered dietitian (RD) conduct an audit to ensure all dietary orders, recommendations, and documentation are accurate in the medical record and match the dietary department's tray ticket information for each resident.
- Review and revise the facility's pertinent menu and therapeutic diet policies.
- Educate the IDT on conducting root cause analysis of serious events, including choking incidents, and ensuring appropriate actions are taken to prevent recurrence.
- Implement daily audits of new admissions by the dietary manager (DM) and the DON or designee to ensure dietary orders/recommendations/documentation are accurate in the medical record and match the dietary department's meal ticket information for that resident, documenting findings on an audit form.
- Have the DON or designee review all new orders to monitor for changes to diet orders; communicate any changed orders to the dietary department through a diet change communication form.
- Monitor food service at all three meals for all residents by the DON or designee, comparing the meal being served to the physician order/documentation for that resident's dietary needs; document findings on an audit form.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to follow neutropenic meal restrictions for a resident receiving chemo. The resident had an order for reverse isolation, but the meal ticket did not identify that fresh fruits and vegetables were prohibited, and meal records showed the resident was served multiple fresh fruits and vegetables. The Dietary Manager stated she was not alerted to the resident’s neutropenic isolation status.
A resident with COPD, schizoaffective disorder, anorexia nervosa, anxiety, and HTN was ordered a regular diet with mechanical soft texture and thin liquids, but was served a whole cube steak instead of the required ground texture. Staff confirmed the resident was on a mechanical soft diet, and the DM verified the meat should have been ground per the ordered diet and the facility's tray identification process.
A resident with dysphagia and cognitive impairment was on a mechanical soft diet when she choked during breakfast and the LPN obtained an order to downgrade her to puree. The next morning, the resident was still served a mechanical soft tray with regular pancakes instead of the ordered puree diet, and she choked again, required CPR, was transported to the hospital, and later died. Staff reported the kitchen had not received a written diet change slip, and the facility had no policy guiding diet order changes.
Pureed foods were not prepared in the proper form for two residents with dysphagia who were on therapeutic diets. Kitchen staff made pureed potatoes, cauliflower, and strawberry crisp using scoops, water, milk, butter, and thickener, but did not perform IDDSI testing and relied on visual judgment for consistency. The RD expected staff to follow IDDSI and recipe directions, but the observed foods appeared thin and inconsistent with the required puree texture.
A resident with dementia and severe cognitive impairment was ordered a mechanical soft diet with nectar-thick liquids, but staff repeatedly provided regular thin liquids instead. Surveyors observed thin juice and water in front of the resident during meals, and staff confirmed the liquids were not nectar thick even though they knew the resident was supposed to receive nectar-thick fluids.
Pureed Foods Served in Improper Consistency: A DM prepared pureed breakfast and lunch items that were observed to contain chunks and a soup-like consistency rather than holding form. The ADM agreed the sausage with gravy and mixed vegetables were not the correct puree consistency, and the DM stated pureed food should be smooth and able to hold form.
Failure to Follow Neutropenic Meal Restrictions
Penalty
Summary
The facility failed to provide meals consistent with neutropenic precautions for one resident, R58, who had been admitted on 04/05/25 and had a physician order dated 01/16/25 for reverse (neutropenic) isolation after receiving chemotherapy. Review of the resident’s meal ticket did not indicate that fresh fruit and vegetables were to be withheld. Review of the facility’s meal records showed that R58 was served multiple fresh fruits and vegetables during the month, including broccoli salad, coleslaw, watermelon, sliced apples, tomato wedges, fresh fruit, creamy cucumber salad, sliced orange, grapes, cucumber/tomato salad, lettuce/tomato/onion, and cucumber salad. During interview on 05/28/26 at 1:38 PM, the Dietary Manager stated she was not alerted that R58 was on neutropenic isolation and therefore could not receive fresh fruit and vegetables. The facility policy titled Nutritional Management stated that the facility provides care and services to each resident to ensure acceptable nutritional status and that interventions will be individualized to address the specific needs of the resident.
Mechanical Soft Diet Not Provided as Ordered
Penalty
Summary
The facility failed to ensure a resident ordered a regular diet with mechanical soft texture and thin liquids received food prepared in the correct form. Resident #38 was admitted with diagnoses including COPD, schizoaffective disorder, anorexia nervosa, anxiety, and hypertension, and the admission MDS indicated intact cognition. The care plan identified the resident as at risk for altered nutritional status due to significant weight loss and included an intervention to provide meals, snacks, and fluids based on food preferences and physician orders. A physician order specified a regular diet with mechanical soft texture and thin liquid consistency. The facility menu for the day indicated cube steak for a mechanical soft diet should be ground and served with gravy, and the resident's meal ticket reflected a mechanical soft diet with an added grilled cheese at each meal. During lunch observation, the resident received a tray that included a whole cube steak rather than a ground texture. A CNA verified the resident was on a mechanical soft diet and confirmed the cube steak was not appropriate, and the Dietary Manager verified the cube steak should have been ground and not served whole. The facility policy stated mechanically altered diets are therapeutic diets and that the food service manager would use a tray identification system to ensure each resident received the ordered diet.
Failure to Follow Ordered Diet After Choking Incident
Penalty
Summary
The facility failed to provide a resident with the physician-prescribed diet, failed to have a policy in place regarding changes in dietary orders, and failed to implement a physician diet order change. The resident had diagnoses including metabolic encephalopathy, osteoarthritis, and dysphagia, and the facility assessment showed moderate cognitive impairment and a need for set-up assistance with meals. The resident was initially on a mechanical soft diet. After the resident was observed coughing and gagging while eating breakfast, the nurse performed the Heimlich maneuver and food was expelled. The on-call provider was contacted and ordered the diet downgraded to puree. A physician order for a pureed texture diet was entered that same day. However, the next morning the resident was served a mechanical soft breakfast rather than the ordered puree diet. Staff reported that the breakfast tray and diet slip still reflected mechanical soft, and the kitchen staff stated they had not received a written diet change slip showing the downgrade. During the second choking event, staff observed the resident coughing while eating breakfast in bed. Abdominal thrusts were attempted, a mouth sweep was performed, 911 was called, CPR was initiated when the pulse could not be obtained, and the resident was transported by EMS to the hospital. The emergency room record states large amounts of pancakes were found in the airway, intubation could not be completed in the field, and the resident died at 8:30 AM. The report states the Immediate Jeopardy began when the diet was changed to puree but the resident was still served mechanical soft food the next morning.
Pureed Foods Not Prepared to Required Texture Standards
Penalty
Summary
The facility failed to ensure pureed food was prepared in the proper form to meet individual resident needs for two sampled residents, both of whom had physician-prescribed therapeutic diets and diagnoses of dysphagia. Resident 4 had dysphagia, unspecified, and Resident 26 had dysphagia, oropharyngeal phase. On the lunch meal tray, both residents were served pureed foods that were prepared in a manner that did not match the expected IDDSI level 4 texture standards described in the facility documents. During kitchen observations, staff prepared pureed potatoes, pureed cauliflower, and pureed strawberry crisp using scoops, butter, hot water, milk, and thickener, but did not test the foods for the proper consistency. The pureed potatoes had flecks of skin and appeared very thin and watery. The pureed cauliflower also appeared thin. The strawberry crisp puree was prepared by eyeing the milk amount and blending without measuring the liquid, and staff stated they were looking for pudding consistency but did not test it. The Certified Dietary Manager later measured the strawberry crisp puree and found the amount in the cups was about one ounce short of filling a #8 scoop, prompting more puree to be made. Staff interviews and facility records showed that the Registered Dietitian expected staff to test pureed foods according to IDDSI and to use the spoon test after preparation. The recipes for the pureed potatoes, cauliflower, and strawberry peach crisp also directed staff to perform IDDSI testing to ensure texture standards were met. Facility in-services on IDDSI and pureed diets were documented, but no competency evaluation was provided for the staff involved in the preparation observed by surveyors.
Failure to Provide Ordered Nectar-Thick Liquids
Penalty
Summary
The facility failed to ensure a cognitively impaired resident with dementia and severe cognitive impairment received liquids in the prescribed nectar-thick consistency. The resident’s physician orders documented a regular mechanical soft diet with nectar consistency liquids, but the care plan lacked documentation of the nectar-thick liquid order. The dietary note stated nursing reported the resident was having trouble swallowing liquids and wanted slightly thickened liquids, and the facility noted that PointClickCare only had nectar thick liquids available as a diet option. During dining room observations, the resident was seen with regular thin liquids in front of her, including apple juice, orange juice, and water. On one occasion, the resident drank a full glass of orange juice and about 100 ml of apple juice before a CNA confirmed the juices were not nectar thick and stated she did not know who gave them to the resident. On another occasion, a CMA observed regular thin water in front of the resident and pushed it away, while dietary staff stated the resident was on nectar thick liquids and that the correct fluids should have been passed. Staff also reported the resident usually liked coffee and that her coffee was nectar thick when prepared by staff.
Pureed Foods Served in Improper Consistency
Penalty
Summary
The facility failed to ensure that pureed foods were prepared in a form designed to meet individual needs for 2 observed meals, breakfast and lunch. During the breakfast observation on 05/20/26 at 7:40 AM, the DM prepared pureed eggs, cream of wheat, and pureed sausage with gravy and provided a sample tray. When the surveyor tasted the pureed sausage with gravy, it contained small chunks of meat and was in a soup-like form, meaning it did not hold shape. During an interview at 7:58 AM, the ADM agreed that the sausage and gravy was not the correct consistency for puree form. During the lunch observation on 05/20/26 at 12:00 PM, the DM prepared pureed chicken, mashed potatoes, bread, and mixed vegetables and provided a sample tray. When the surveyors tasted the pureed mixed vegetables, they found small chunks and a soup-like form, meaning it did not hold shape. During an interview at 12:10 PM, the ADM agreed that the mixed vegetables were not the correct consistency for puree form. On 05/21/26, the DM stated she had been trained on puree form and to mix it so there were no chunks of food, and that pureed food should be smooth and able to hold form. The ADM stated she expected pureed foods to be safe and proper in consistency every time they were sent to residents and did not know why the foods were sent out when not in proper form.
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