Failure to Provide Ordered Altered Texture Diet Resulting in Fatal Choking Event
Summary
The deficiency involves the facility’s failure to provide an altered texture diet as ordered by the physician for a resident with dysphagia, resulting in a choking event and death. Facility policy on dysphagia diets required that individuals with signs of swallowing difficulty be evaluated by a speech therapist (ST), with the ST and registered dietitian (RD) making recommendations to the physician for appropriate food and fluid consistencies, and the culinary department responsible for preparing and serving diets as ordered. The facility had implemented the International Dysphagia Diet Standardization Initiative (IDDSI) framework, including Level 7 Easy to Chew foods and Level 5 Minced and Moist meats, and policy stated that care would be taken to serve foods and fluids as ordered on altered consistency diets. The resident at issue had diagnoses including high blood pressure, malnutrition, and muscle wasting, and had been treated by speech therapy for dysphagia. Following this evaluation, the physician ordered a diet consisting of no added salt, low potassium, Level 7 Easy to Chew texture, Level 5 minced and moist meats, Level 3 moderately thick liquids, and a 1500 ml fluid restriction. Despite these specific orders, on the day of the incident the resident was served a regular hamburger that did not conform to the ordered minced and moist meat texture. Written statements from dietary aides indicated they could not recall whether the correct 7EC/5MM burger had been placed on the resident’s plate, and a nurse aide reported that she delivered the lunch tray, saw the burger, but did not realize it was the wrong texture and did not look at what was served beyond seeing the burger. During the choking event, the resident’s daughter alerted nursing staff that the resident appeared to be choking. An LPN and RN responded immediately from the hallway, observed the resident choking and unable to clear food from the airway, and the RN initiated the Heimlich maneuver. When the obstruction was not relieved and the resident became cyanotic, the resident was placed on a backboard, abdominal thrusts were continued, food material was visualized in the oral cavity, and suction was used to remove visible particles. After the food bolus was dislodged, the resident had shallow respirations and a very low pulse, and subsequently ceased breathing with family present. The ST confirmed that, based on the prior dysphagia evaluation and the IDDSI standards, the resident should not have received a regular hamburger and instead should have received minced and moist meat mixed with gravy or sauce. The investigation also identified systemic issues in how diet orders were communicated and incorporated into resident care. Review of the resident’s care plan showed that it did not include the specific physician-ordered diet of NAS, low potassium, Level 7 Easy to Chew, Level 5 minced and moist meats, Level 3 moderately thick liquids, and 1500 ml fluid restriction. A review of additional records for residents on altered texture diets found that four of five sampled residents did not have their altered texture diets listed as approaches in their plans of care. The RD stated that diet orders were not listed in care plans beyond a generic “provide diet as ordered” because diets were subject to change. The facility’s tray tickets used abbreviations such as “7EC, 5MMM, NAS, Mod” and listed general preferences like “hamburger” without specifying the required minced and moist texture, and did not spell out the full diet orders or specific texture-modified items. Surveyors determined that this failure to provide the ordered altered texture diet for one resident, and similar risks for 40 residents on altered texture diets, resulted in an Immediate Jeopardy situation.
Penalty
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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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