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:
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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