F0805

J

Failure to Provide Ordered Dysphagia Diet Textures Resulting in Choking Event and Ongoing Meal Service Errors

Fort Collins, Colorado Survey Completed on 02-09-2026

Penalty

No penalty information released

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.