Failure to Follow Mechanical Soft Diet Orders Resulting in Choking Episode
Summary
The deficiency involves the facility’s failure to provide a resident with food in the physician-ordered mechanical soft, ground meat form. The resident had diagnoses of dysphagia, oropharyngeal phase dysphagia, and Alzheimer’s disease, with a BIMS score of four indicating severe cognitive impairment. Her MDS and CAAs documented that she coughed or choked during meals or when swallowing medications and that she required a mechanically altered diet. The care plan and EMR orders specified a regular diet with mechanical soft texture, ground meat with gravy or sauce (no dry meat), and multiple restrictions including no soft tortilla shells, no salad, no raw onions, no raw vegetables, and tortilla chips to be crushed or broken. An intervention also directed staff to cut up her food and remind her to take only one bite at a time. Despite these documented needs and orders, on the day of the incident the resident was served a whole chicken strip instead of ground meat. A nurse’s note recorded that the resident received a whole chicken strip for lunch and choked on a bite of chicken. Staff statements confirmed that dietary staff provided a whole chicken strip, and one dietary staff member stated he had chopped one up but then set it aside and gave her a whole chicken strip because he could not remember if they were supposed to be chopped for her. This action directly conflicted with the resident’s ordered mechanical soft diet with ground meat and the facility’s own policies requiring foods to be cut, chopped, or ground to meet individual needs and specifying that meat, fish, and poultry on mechanical soft diets should be chopped, flaked, or ground. When the resident began choking, another resident alerted staff in the dining room. Staff observed the resident choking, and a CNA and another staff member attempted and then performed the Heimlich maneuver, resulting in the resident expelling a chunk of food onto the floor and stating she felt better. A prior progress note also documented that the resident had experienced a possible choking episode in the dining room on an earlier date, during which she was observed coughing with blue lips, encouraged to cough up a moderate amount of mushy substance, and suctioned for a moderate amount of thick, clear mucus. The facility’s dietary and nursing staff interviews described an established process using diet cards and multiple verification steps to ensure correct diet texture and consistency, but staff acknowledged that this process was not thoroughly followed for this resident’s meal, resulting in her receiving a full chicken strip instead of the ordered mechanical soft, ground meat diet. This failure led to a choking episode that surveyors determined constituted Immediate Jeopardy.
Removal Plan
- Provide in-service education for dietary monitoring and ensuring proper diets are served to each resident for direct-care staff and kitchen staff
- Provide 1:1 education with the cook and dietary aide
- Implement disciplinary action for the cook and dietary aide
- Provide 1:1 in-service education with all staff who serve in the dining room
- Revise the dining room monitoring schedule to include manager coverage for all meals
- Verify all at-risk residents to ensure diets match their diet cards
- Provide RELIAS educational training for the cook
- Hold a QAPI meeting with the Director of Nursing, Administrator, and Medical Director
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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