Failure to Follow Therapeutic Diet Order Results in Fatal Choking Incident
Summary
A facility failed to ensure that a resident received a therapeutic diet as ordered by the physician, resulting in a fatal choking incident. The resident, who had a history of cerebrovascular disease, anoxic brain damage, dementia, dysphagia, and other significant medical conditions, was prescribed a pureed diet with nectar-thickened liquids due to severe swallowing difficulties. Despite these orders, a Certified Nurse Assistant (CNA) provided the resident with a peanut butter sandwich, which was not permitted on the prescribed diet. The CNA was aware of the resident's dietary restrictions but gave the sandwich at the resident's request, having previously observed the resident eat similar food without apparent difficulty. The incident occurred when the resident began eating the peanut butter sandwich and subsequently choked, leading to a loss of pulse. Staff attempted the Heimlich maneuver and initiated CPR, but the resident was ultimately transferred to a hospital and expired. The official cause of death was listed as choking on a food bolus. Interviews with staff confirmed that the CNA did not verify the resident's current diet order through available resources such as the KARDEX, care plan, or by consulting a nurse, despite being aware of the resident's dietary restrictions and the facility's protocols for verifying diet orders before providing snacks. Further review revealed that the facility's policies required snacks to be compatible with therapeutic diets and that staff were trained to check diet orders before providing food to residents. However, there was no specific policy or standard provided regarding acceptable food items for different therapeutic diets. The resident had a documented history of swallowing disorders and previous choking incidents, including a prior event involving a peanut butter sandwich that led to a change in diet orders and additional speech therapy interventions. Despite these measures, the failure to follow the prescribed diet directly resulted in the resident's death.
Removal Plan
- All mechanical soft and pureed snacks in the snack room and refrigerator were labeled by the Dietary Manager with the appropriate consistency.
- The Administrator reviewed all snacks and supplemental foods available outside of meal service to ensure compliance with current diet orders.
- Education was initiated by the Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator for all licensed nurses, certified medication technicians, and certified nurse aides.
- Staff were instructed on the new process for labeled snacks, the requirement to verify diet orders through the Kardex, care plan, or physicians' order, and the inappropriateness of peanut butter on a pureed diet unless blended to proper consistency under IDDSI standards.
- All staff completed return demonstrations prior to working their next scheduled shifts, and competency validation was confirmed.
- A 100% audit of all resident diet orders and Kardex entries was completed by the DON, MDS nurse, and Regional Nurse.
- The ADON completed a 100% audit of all physician diet orders in Point-Click-Care against tray tickets to ensure accuracy.
- Ongoing monitoring was implemented, including nursing audits of 10 trays per week for four weeks, followed by 10 trays monthly for three months.
- The Administrator audited snacks three times per week for four weeks, then decreased frequency over the following two months.
- All new hires will receive training on therapeutic diets, Kardex review, and snack verification during orientation prior to assuming care responsibilities.
- The QAPI Committee held an ad hoc meeting to review corrective actions, with a monthly follow-up scheduled for three months.
- The Medical Director was notified of all corrective measures and ongoing monitoring efforts and agreed with the plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to follow its own menu extension sheets, production sheets, and recipes when serving a main meal, resulting in several residents receiving only one manicotti instead of the two portions specified on their tray tickets and the planned menu. Policies required that recipes be followed exactly and that production sheets list correct portion sizes and quantities, and the recipe defined one manicotti portion as 6 oz. During tray line service, a dietary employee chose to serve only one manicotti based on personal judgment that the items were “pretty big,” and subsequent review and weighing by the dining services director confirmed that the served portion did not meet the specified recipe portion size.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
Surveyors found that the facility did not follow its dietitian-approved lunch menu when a scheduled meal of BBQ chicken, pasta salad, stewed tomatoes, cornbread with margarine, and fruit was replaced with baked chicken, corn, mashed potatoes, and a cookie without documented, dietitian-approved substitutions. The Owner reported allowing the cook to make like-for-like substitutions and acknowledged that a dietitian should approve such changes, while the Administrator stated the Owner changed the meal due to lack of kitchen help and noted potential risk of weight loss if meals are not nutritionally equivalent. Review of the facility’s policy showed that menus must be prepared in advance, approved by a dietitian, and that all substitutions must be documented the day they occur.
The facility did not follow its menu and portion control procedures for residents on mechanically altered diets, as a dietary aide served mechanically altered beef stroganoff using a #12 scoop and provided only one scoop instead of the required portion. The diet extension sheet and scoop size chart showed that a larger #6 scoop, or two #12 scoops, was needed to meet the planned serving size, but three residents on mechanically altered diets received less than the specified amount of meat. The regional dietary manager and the dietary aide confirmed the incorrect scoop size and portion used, contrary to facility policy requiring appropriate portions to ensure nutritional adequacy.
Incorrect portion sizes were served during lunch when a dietary aide used a #20 scoop instead of the required #16 scoop for a pureed roll and an ADM served only 1/2 cup of chicken cacciatore instead of the ordered 1 cup. Staff said they did not verify the extended menu before serving, and the Dietary Mgr and ADM acknowledged the menu should have been followed.
Surveyors found that the facility did not follow the dietitian-approved pureed menus for several residents on pureed diets. A resident reported being repeatedly served mashed potatoes and stated that requests for different food were not honored, while another resident complained that her pureed meal was the same “mush” every day despite being able to chew. Observation of a lunch meal showed that residents on pureed diets received pureed peas, mashed potatoes, chicken, and ice cream instead of the planned pureed chicken soft tacos, refried beans, chef’s choice vegetable, and churros. The Dietary Manager and dietary staff confirmed that the cook did not follow the written pureed menu or recipes and substituted items, including replacing pureed refried beans with mashed potatoes and pureed churros with ice cream.
Failure to Follow Menu and Recipe Portion Sizes for Entrée Service
Penalty
Summary
The deficiency involves the facility’s failure to follow its own menus, production sheets, and recipes to provide correct portion sizes for the planned meal. Facility policies titled “Recipes” and “Production Sheet,” last reviewed March 23, 2026, require that recipes be used for all menu items, adjusted for facility yield, and followed exactly, and that production sheets list all items, recipe numbers, portion sizes, and quantities to be produced based on the resident diet census. The menu extension sheet for a specified Wednesday main meal indicated that residents were to receive two baked manicotti with tomato sauce (6 ounces per portion), 4 ounces of vegetable blend, a 2‑ounce warm dinner roll with butter, and one slice of pound cake with fruit topping. During observation of the tray line meal service, five residents with similar diet needs were each served only one manicotti instead of the two specified on their tray tickets and the menu extension sheet. When the surveyor raised this concern, a dietary employee stated that the manicotti were “pretty big” and estimated each at least three ounces, so he only served one. Review of the facility recipe showed that one portion of manicotti was defined as 6 ounces. The Director of Dining Services weighed one manicotti from the steam table and found it to be approximately 5 ounces, and agreed this was not the correct portion size. The Nursing Home Administrator stated she would expect recipes to be followed and appropriate portions to be served during meal service.
Plan Of Correction
1. Facility cannot correct the inaccurate portion size served to the 5 residents observed during meal service during survey. Residents able to request additional serving of meal following original meal provided. 2. Appropriate portion sizes were provided to remaining residents moving forward following observation of the 5 residents during survey. 3. Education provided to cooks on following recipes and serving appropriate portion sizes. 4. Audit of random meal service will be completed daily for 2 weeks, then 3 times a week for 2 months. Audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Follow Dietitian-Approved Lunch Menu and Document Substitutions
Penalty
Summary
The facility failed to ensure that the lunch meal served on 04/30/2026 followed the planned, dietitian-approved menu. The written menu for that date (week 3 at a glance) listed BBQ chicken, pasta salad, stewed tomatoes, cornbread with margarine, a summer fruit cup, and a beverage. However, during observation of the lunch meal, residents were instead served baked chicken, corn, mashed potatoes, a cookie, and beverages. This discrepancy showed that the planned menu was not followed for the one observed meal. During interviews, the Owner stated that the cook was allowed to make food substitutions with like food items and acknowledged that a dietitian should approve substitution meals. The Administrator reported that the change in the meal was the Owner’s decision due to not having kitchen help and stated that if meals do not share equal nutrients, there could be a risk of weight loss for residents. Review of the facility’s “Alternative and Substitute Menu Policy” dated 1/1/2025 showed that menus must be prepared at least one week in advance, reviewed and approved by the facility’s qualified dietitian, and that all substitutions must be documented on the day of occurrence, indicating that the observed practice did not align with the written policy.
Incorrect Portion Sizes for Mechanically Altered Meat
Penalty
Summary
The facility failed to ensure that menus were followed and that residents on mechanically altered diets received the correct portion size of meat as planned on the menu. During observation of the lunch tray line, a dietary aide was seen serving mechanically altered beef stroganoff using a green-handled #12 scoop and providing only one scoop per meal to residents on mechanically altered diets. The diet extension sheet specified that mechanically altered meat was to be served with a #6 scoop, and the facility’s scoop size chart showed that a #12 scoop provides 2.78 ounces while a #6 scoop provides 4.66 ounces. The regional dietary manager confirmed that when using a #12 scoop, two scoops should have been given to meet the required portion size, and the dietary aide acknowledged that only one scoop had been provided to each resident receiving mechanically altered beef. Record review confirmed that three residents were on mechanically altered diets at the time, and facility policy on portion control required that residents receive appropriate food portions to ensure nutritional adequacy. This deficiency represents non-compliance investigated under the cited complaint numbers related to failure to provide correct serving sizes for mechanically altered meat for three residents receiving mechanically altered diets.
Incorrect Portion Sizes Served at Lunch
Penalty
Summary
The facility failed to ensure menus were followed for the lunch meal and that the portions served matched the extended menu. During observation and interview in the kitchen on 04/27/2026 at 11:22 AM, [NAME] B served the lunch meal for residents who ate in the halls and used a #20 scoop to serve the pureed bread, even though the extended menu required a #16 scoop for the pureed wheat dinner roll. During observation and interview in the main dining room on 04/27/2026 at 11:43 AM, the Assistant Dietary Manager said she was using only 1/2 scoops to serve the lunch meal and served 1/2 cup of chicken cacciatore to residents in the main dining room, while the extended menu required 1 cup of Chicken Cacciatore Pasta. During interview on 04/28/2026, [NAME] B said she normally checked the extended menu before serving but did not do so on 04/27/2026 because the same scoop sizes are usually used for each meal. She acknowledged the #20 scoop was smaller than the required #16 scoop and said using the smaller scoop could mean residents were not getting enough food. The Assistant Dietary Manager said she also did not check the extended menu on 04/27/2026 because she was not supposed to serve the lunch meal, and she stated that serving less than required could leave residents underfed and lead to malnutrition. The Dietary Manager and Administrator both stated they expected staff to use the correct scoop sizes and that not doing so could lead to residents receiving less nutrition and weight loss.
Failure to Follow Dietitian-Approved Pureed Menus for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow menus prepared in advance and approved by a Registered Dietitian for residents on pureed diets. A complaint was received alleging that one resident on a pureed diet had been served mashed potatoes for two meals per day for a year, and that the resident’s requests for different meal options were not honored. During observation in the dining room, this resident stated that the food was getting better but that he still received a lot of mashed potatoes. Another resident on a pureed diet pointed to her plate and complained that her meal was “all mush” and “the same mush every day,” stating that she could chew. Her plate contained pureed peas, pureed mashed potatoes, and pureed chicken. Further review of the lunch meal service showed that residents on pureed diets, including six identified residents, were served pureed peas, pureed mashed potatoes, pureed chicken, and ice cream for dessert, while other residents received chicken soft tacos, refried beans, corn, and churros. The Dietary Manager presented the planned menu and pureed diet extension, which specified pureed chicken soft tacos, pureed refried beans, pureed chef’s choice vegetable (not corn), and pureed churros. The Dietary Manager acknowledged that the cook had not followed the menu, substituting mashed potatoes for pureed refried beans. Dietary staff confirmed that the cook did not follow the pureed chicken soft tacos recipe, did not prepare pureed refried beans, and instead made mashed potatoes, and that residents on pureed diets did not receive the planned pureed churros dessert but were given ice cream cups. The Registered Dietitian–prepared menu and recipes, which provided variety for pureed diets, were reviewed and it was agreed they had not been followed.
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