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:
A resident with swallowing precautions and a cardiac diet was observed eating lunch in bed at less than 90 degrees, without staff present, and with a sandwich that was not clearly cut into bite-size pieces as ordered. Staff interviews showed confusion about whether the positioning and food-preparation instructions were official orders, and the resident’s chart contained mixed directions about meal setup and swallow precautions.
Improper Texture of Pureed Foods: Puree items on the trayline were observed to be flat, spread out, and watery rather than holding their shape. No spoon tilt test or fork pressure test was observed during service, and the DS and RD stated the food did not meet IDDSI Level 4 expectations for residents with swallowing difficulty.
Surveyors found that two residents with ordered mechanically altered diets did not consistently receive food in the prescribed texture, and that staff did not reliably verify food consistency before trays left the kitchen. One resident on a mechanical soft/easy‑to‑chew diet was observed receiving hard broccoli, intact meat later cut by staff, and large pieces of fruit, which the resident reported were difficult to chew and swallow. Another resident with dysphagia on a minced and moist diet was served a whole cheese sandwich with bread edges, apple pie with crust, and soup containing bacon and vegetables, and reported that the food pieces were too large and not easy to swallow. CNAs stated that sandwiches arrived whole and were cut by nursing staff without clear guidance on size, while the Dietary Supervisor and DON confirmed that dietary staff were responsible for preparing correct textures and that both dietary and nursing staff were expected to check food consistency against facility policies for mechanical soft and minced and moist diets.
Two residents with dementia, dysphagia, and prior stroke were ordered IDDSI 5 and 6 modified diets with specific texture and supervision requirements, but staff routinely provided crustless peanut butter and jelly sandwiches that were not permitted or properly prepared under those IDDSI levels. One resident, ordered a level 6 soft and bite-sized diet with supervision, was habitually given halved peanut butter and jelly sandwiches without an SLP-approved exception and experienced a choking episode in the dining room that required an LPN to perform the Heimlich maneuver. The other resident, ordered a level 5 minced and moist diet with honey-thick liquids per SLP recommendations, continued to receive crustless peanut butter and jelly sandwiches with every meal based on nursing-entered orders that were not supported by SLP evaluation or the diet slip. Dietary staff prepared sandwiches only crustless and cut in halves or quarters, not into IDDSI-compliant bite-sized or minced pieces, and multiple NAs and nursing staff reported they were unaware that peanut butter and jelly sandwiches and nut butters were not allowed on these modified diets or where to find IDDSI guidance, despite facility policies requiring adherence to physician/SLP diet orders and the diet manual.
The facility failed to prepare and provide food in the correct pureed consistency for several residents with physician-ordered pureed diets. During a lunch meal observation, pureed rice on the steam table was found to be gritty with large clumps instead of smooth, and the Dietary Supervisor confirmed it was not the correct puree texture. Review of the diet list showed multiple residents were ordered pureed diets, and facility policy defined therapeutic diets, including texture-modified diets, as physician- or practitioner-ordered as part of treatment for clinical conditions.
A resident admitted with acute kidney failure had a dietary order for no added salt, fluid restriction, thin liquids, and a renal diet. During tray line observation, the meal ticket listed a regular diet and the tray included a salt packet, which the DM validated. The resident’s order and the renal diet guidance both called for low salt restrictions.
Food Not Prepared or Served per Resident Swallowing Needs
Penalty
Summary
The facility failed to ensure food was prepared and served in a form designed to meet one resident’s individual needs. The resident had speech therapy recommendations for safe swallowing precautions, including being seated at 90 degrees for all oral intake, receiving one-to-one assistance to use small bites and sips, eating at a slow rate, alternating bites and sips, and being fed only when alert. The resident’s MDS identified intact cognition and set-up assistance with eating, and the care plan directed staff to assist with meal set-up and to keep the resident as upright as possible when eating in bed, with encouragement to sit in a wheelchair for meals. Physician orders also included a cardiac diet with instructions to cut food into small bite-size pieces and to maintain the 90-degree positioning and other swallow precautions. During observation, the resident was eating lunch in bed with the head of the bed raised to about 75 degrees rather than 90 degrees. The lunch tray was on a bedside table, and the resident was eating a half-submarine sandwich with large pieces of lettuce and tomato while no staff were present in the room. Staff interviews showed confusion about the resident’s orders: one TMA stated she was not aware the food had to be cut into bite-size pieces, a NA said the care plan identified cut-up food but did not direct staff to ensure a 90-degree position, and a dietary aide stated dietary staff were supposed to cut up ordered foods but was not sure whether the sandwich had been cut. A RN stated the special instructions were not an official order and were additional notes left on the chart after the resident returned from the hospital.
Improper Texture of Pureed Foods
Penalty
Summary
The facility failed to prepare puree foods in a form designed to meet individual needs for residents on an IDDSI Level 4 puree diet. During observation of the trayline and plated meals, the pureed capri blend vegetables looked flat and spread out on the plate, and the puree spring fruit crisp appeared watery and did not hold its shape. No spoon tilt test or fork pressure test was observed being performed by kitchen staff during trayline service to verify the texture and consistency of the pureed foods. During interview, the Dietary Supervisor stated the pureed capri blend vegetables did not hold their shape and the puree spring fruit crisp looked watery, and that pureed food should not look flat or watery because residents could choke and aspirate. The Registered Dietitian stated staff should perform spoon tilt and fork pressure tests when making food and during trayline to ensure the correct texture for residents with difficulty swallowing and eating. Facility documents for the IDDSI Level 4 pureed diet and related recipes stated the food should be smooth, free of lumps, hold its shape, and not weep, and the IDDSI guidance stated Level 4 pureed food should hold shape on the plate and not allow liquid to separate from solid.
Failure to Provide Ordered Texture‑Modified Diets and Verify Food Consistency Before Service
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed texture‑modified diets and to ensure appropriate texture checks before food left the kitchen for two residents with ordered mechanically altered diets. For the first resident, who had respiratory failure and heart failure and was care planned for a therapeutic diet with monitoring for signs of swallowing difficulty, the clinical record showed an order and nutrition note for a mechanical soft/easy‑to‑chew diet. Despite this, surveyors observed the resident receiving meat and broccoli that were not in a mechanical soft consistency. The resident reported that meat was served in one piece and only cut into smaller pieces by staff, and that the broccoli was hard rather than soft, requiring prolonged chewing to swallow. On another observation, the resident was served grapes cut in half with skins on and melon cut in rectangular pieces, which the resident stated looked too large and declined to eat. The second resident had cerebrovascular disease, dysphagia, and vascular dementia with fluctuating decision‑making capacity, and was care planned for a therapeutic, mechanically altered diet with monitoring for pocketing, choking, coughing, drooling, and multiple swallowing attempts. The record documented an order for a minced and moist diet three times daily. However, surveyors observed this resident receiving a whole cheese sandwich with bread edges, apple pie with crust, and vegetable soup with bacon and carrots. The resident stated that the sandwich was cut into pieces by nursing staff but the pieces were still large and not easy to swallow, and that food provided was not easy to chew and was not cut into small pieces as needed for their condition. Staff interviews further described how these incorrect textures reached the residents. The Dietary Supervisor stated that a mechanical soft diet should consist of soft, easy‑to‑chew foods, with broccoli chopped into small pieces, and that a minced and moist diet required food to be wet, ground, and finely minced, with apple pie and bread edges not acceptable due to chewing difficulty. The facility’s policies for Level 7 Regular Easy to Chew and Level 5 Minced and Moist specified that meats should be chopped into 1/2‑inch or smaller or minced to 2–4 mm, moist, and cohesive, and that hard, sticky, or crunchy foods were excluded. The Dietary Supervisor acknowledged that dietary staff, including the supervisor, were responsible for checking food texture before trays left the kitchen. CNAs reported that sandwiches arrived whole from the kitchen and were cut by CNAs into bite‑size pieces without clear guidance on the required size, and that some items, such as pie, were too hard and needed further cutting. The DON stated that therapeutic diets were ordered for resident safety, that dietary staff were responsible for providing the correct texture, and that nursing staff were responsible for checking all residents’ food before delivery, underscoring that correct food texture was important to prevent choking.
Failure to Follow IDDSI-Consistent Modified Diet Orders and Staff Incompetence With Texture Restrictions
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed modified-texture diets in accordance with physician orders, the diet manual, and IDDSI guidelines, and failure to ensure staff competency with IDDSI diets for two residents with dysphagia. Resident #1 had dementia, oropharyngeal dysphagia, cerebrovascular disease, and type II diabetes, with a physician’s order for a regular diet with IDDSI 6 soft and bite-sized texture and thin liquids, use of adaptive equipment, and supervision with meals. Despite these orders and a care plan identifying potential swallowing problems and the need for supervision and adherence to the prescribed diet, Resident #1 was routinely provided peanut butter and jelly sandwiches that were crustless and halved, not cut into 1.5 cm by 1.5 cm pieces as required for IDDSI 6, and peanut butter was not permitted on that texture level per IDDSI guidance. Staff, including nursing and dietary, reported that Resident #1 “always” received peanut butter and jelly sandwiches with meals and as snacks, and there was no SLP evaluation or physician order authorizing an exception for peanut butter and jelly sandwiches. On the day of the choking incident, Resident #1 was in the dining room eating lunch when a choking episode occurred, requiring an LPN to perform the Heimlich maneuver, which dislodged a piece of food and the resident’s dentures. The SLP present in the dining room for another resident heard banging, turned to see Resident #1 red in the face and apparently not breathing, and alerted the LPN, who then intervened. The SLP later stated that the choking incident could have been prevented if the resident’s diet orders had been followed and confirmed that peanut butter and jelly sandwiches are not included in a level 6 diet unless specifically evaluated and ordered as an exception, with the sandwich cut into 1.5 cm by 1.5 cm pieces. Multiple NAs and an LPN reported they were unaware that peanut butter and jelly sandwiches were not permitted on a level 6 diet, did not know where IDDSI guidance was posted, and believed the resident could have peanut butter and jelly sandwiches. The Food Service Director confirmed that Resident #1’s meal tickets included a peanut butter and jelly sandwich at each meal without any supporting diet order slip and that sandwiches for residents on modified diets were only made crustless and cut in half, not into IDDSI-compliant bite-sized pieces. Resident #2 had oropharyngeal dysphagia and a history of cerebral infarction, with an initial physician’s order for a regular diet with IDDSI 6 soft and bite-sized texture and honey-thick liquids, and permission for soft crustless sandwiches including peanut butter and jelly, with supervision at meals. A subsequent SLP screen identified overt signs of aspiration and led to a change in diet to IDDSI 5 minced and moist texture with honey-thick liquids. The SLP’s discharge summary recommended continuing IDDSI 5 minced and moist and honey-thick liquids and did not document that the resident was safe to consume peanut butter and jelly sandwiches or that any exception was approved. Nonetheless, nursing entered physician orders on two later dates allowing crustless peanut butter and jelly sandwiches with every meal, and these orders remained in effect. The clinical record from the SLP discharge forward did not show any SLP evaluation approving peanut butter and jelly sandwiches for this resident. Observations in the dining room showed Resident #2 being served crustless peanut butter and jelly sandwiches with meals, first halved and later quartered, while on an IDDSI 5 minced and moist diet, despite IDDSI guidance that this level excludes regular dry bread and sticky foods such as nut butters and requires food to be soft, moist, and minced into 4 mm pieces. NAs confirmed that the resident always received a crustless peanut butter and jelly sandwich with meals. The SLP later clarified that although she had trialed crustless peanut butter and jelly sandwiches during therapy, the resident was not safe to consume them without one-to-one SLP observation and that her written diet slip at discharge did not authorize peanut butter and jelly sandwiches. The APRN acknowledged signing the peanut butter and jelly sandwich orders in bulk, assuming SLP approval, and the DON stated she did not know why nursing entered those orders when they were not recommended by the SLP. Facility policies required that residents receive foods in the consistency ordered by the physician and/or speech therapy, that diet textures follow the diet manual and be transcribed correctly to diet cards, that texture needs be guided by the speech therapist or dietician, and that food on the tray match the dietary card, but these requirements were not followed for the two residents. Overall, the deficiency centers on the facility’s failure to follow physician and SLP diet orders and IDDSI standards for modified textures, specifically by providing peanut butter and jelly sandwiches that were not permitted or properly prepared for residents on IDDSI 5 and 6 diets, and on staff’s lack of knowledge and competency regarding IDDSI diet restrictions and preparation. This resulted in residents with dysphagia receiving food items and textures inconsistent with their ordered diets and the facility’s own policies.
Failure to Provide Proper Pureed Diet Consistency
Penalty
Summary
The facility failed to ensure food was prepared in accordance with physician-ordered pureed diet consistencies for residents requiring texture-modified diets. During observation of the lunch meal service, pureed rice intended for residents on pureed diets was found in the warming table and, upon taste testing by the surveyor and the Dietary Supervisor, was noted to be gritty in texture with large clumps rather than smooth as required for puree consistency. The Dietary Supervisor confirmed that the rice did not meet the expected smooth, lump-free puree standard. Review of the facility diet list showed that six residents had physician orders for pureed diet consistency, and review of the facility’s therapeutic diet policy indicated that such diets are ordered by a physician, practitioner, or dietitian to alter the texture of the diet as part of treatment for a disease or clinical condition. This deficiency was cited under Complaint Number 2961570. The deficiency involved the facility’s failure to properly prepare and provide pureed food in the correct consistency for residents with physician-ordered pureed diets, as evidenced by the improperly prepared pureed rice and confirmation by the Dietary Supervisor that it did not meet puree standards.
Dietary Order Not Followed for Resident on Renal Diet
Penalty
Summary
The facility failed to meet the dietary prescription for one resident, who was admitted with diagnoses including acute kidney failure, unspecified. During a concurrent observation and interview at the tray line, the meal ticket for the resident indicated Regular, Fluid Restriction 1500 ml Thin Liquids, and Renal Diet, and the tray was observed with a salt packet; the Dietary Manager validated this observation and stated they would double check the dietary prescription. During a later interview and record review, the resident’s dietary order was reviewed and showed No added Salt. A review of the facility’s Renal Diet 40-60-80 Gram Protein Low Potassium, Low Salt Menu stated that the diet should include restrictions such as potassium, sodium, and fluid, with low potassium and low salt recommended.
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