Improper Diet Texture and Lack of Meal Supervision Lead to Fatal Choking Event
Summary
The deficiency involves the facility’s failure to ensure a resident received food in the correct mechanically altered texture as ordered and to accurately assess and implement needed supervision during eating. The resident had a physician’s order for a low concentrated sweet, no added salt, mechanical soft diet with thin liquids and a divided plate. The care plan and Nutrition and Hydration Status Assessment documented that the resident had chewing problems and required supervision or assistance at mealtimes, including that the resident fed self with supervision. Speech therapy records showed a history of dysphagia, aspiration pneumonia due to food inhalation, cerebrovascular disease, hemiplegia, and muscle weakness, with recommendations for mechanical soft/chopped textures, upright positioning, alternating food and liquids, and small bites. The resident’s DOSS score indicated restricted diet consistencies and a need for distant supervision during meals. On the day of the incident, a CNA who knew the resident was on a mechanical soft diet provided a regular-texture ham sandwich as an evening snack after the resident requested a sandwich. The CNA later admitted she was aware of the altered diet order but believed the thinly sliced ham was acceptable, even though it was not chopped or otherwise modified to a mechanical soft consistency. The DON confirmed that the ham sandwich given was not of the appropriate texture for a mechanical soft diet. The resident was not being supervised while consuming this snack, despite documentation in the Nutrition and Hydration Status Assessment that the resident required supervision during meals. The DON stated she interpreted “supervision” on the assessment as only meaning set-up assistance, and the dietetic technician later stated that the documentation of supervision needs on the assessment was a human error and that the resident only required set-up assistance. Later that evening, during medication pass, an RN observed the resident in the doorway of his room in a wheelchair, clutching his throat with both hands and attempting to gag himself with his finger. The RN asked if he was choking, and the resident nodded yes but was unable to cough or speak. The RN inspected the resident’s mouth and did not see an obstruction, then called for help and initiated the Heimlich maneuver and back blows. Multiple staff, including CNAs and a respiratory therapist, responded and each attempted the Heimlich maneuver without success. The resident became unresponsive and pulseless, and staff initiated CPR with use of a backboard, crash cart, oxygen, and bag-valve-mask ventilation until EMS arrived. EMS found the resident pulseless and apneic with a reported full airway obstruction, used video laryngoscopy and forceps to remove a large piece of meat completely obstructing the trachea, and then intubated and resuscitated the resident before transferring him to the hospital. Hospital records and the death certificate documented that the resident experienced acute hypoxic respiratory failure, aspiration pneumonia, cardiac arrest, and ultimately anoxic brain death due to choking on food.
Removal Plan
- RN responded to Resident #77, EMS was called, and the resident was transferred to the hospital.
- RN notified Resident #77's physician of the incident.
- The DON reviewed Resident #77's diet order for accuracy.
- The DON initiated an investigation of events surrounding Resident #77's choking incident.
- The DON conducted a root cause analysis and determined Resident #77 choked when CNA #151 provided Resident #77 with the incorrect diet texture during the evening snack.
- The DON reviewed all facility residents' care plans to ensure they accurately reflected current diet orders.
- The DON conducted a full house audit to ensure no additional residents received incorrect diet consistency or improper feeding assistance.
- The DON educated CNA #151 on ensuring each resident received their diet as ordered.
- The DON educated all nursing staff and the Dietetic Technician on ensuring resident care plans accurately reflected current diet needs.
- The DON educated all nursing staff on the facility policy to ensure each resident received their diet as ordered and where to verify a resident's diet order.
- The Administrator, the DON, the LPN/UM, the RDO, and the RCD reviewed facility policies on assisting residents with in-room meals, snack serving, and therapeutic diets.
- An ad hoc QAPI meeting was held to review the choking incident and the facility's corrective action plan.
- The Dietary Manager posted a list of mechanical soft approved foods in the nutrition rooms on each floor of the facility.
- The Dietary Manager posted a list of residents with mechanically altered diets in the nutrition rooms on each floor of the facility.
- The Dietary Manager and/or designee will monitor and update the lists as diet orders change, with new admissions, and as needed.
- The Dietary Manager placed separate bins identifying regular snacks and mechanically altered snacks in the nutrition rooms.
- The Dietary Manager and/or designee will ensure appropriate food items are placed in each bin based on safe foods for each diet texture.
- The DON will audit nursing staff to ensure understanding of mechanically altered diets, with results reported to the QAPI committee.
- The DON will audit residents to ensure meals and snacks being served are appropriate based on the ordered diet, with results reported to the QAPI committee.
- The DON audited all Nutrition and Hydration Status Assessments to ensure accuracy regarding residents' feeding capabilities, including supervision and assistance.
- Any inaccuracies in Nutrition and Hydration Status Assessments were corrected immediately by the Dietetic Technician.
- The DON reviewed all residents' care plans to ensure they accurately reflected the residents' feeding and eating capabilities, including supervision and assistance.
- The DON educated all nursing staff on following the care plan and Kardex to identify a resident's level of assistance required when eating.
- The Registered Dietitian educated the Dietetic Technician on completing Nutrition and Hydration Status Assessments to accurately reflect a resident's level of assistance required when eating.
- The DON will audit residents to ensure they are receiving feeding assistance and supervision as needed, with results reported to the QAPI committee.
- The DON will complete random audits of resident charts for the most recent admission, quarterly, and change of condition Nutrition and Hydration Status Assessments for accuracy of the resident's level of assistance required when eating, with results reported to the QAPI committee.
Penalty
Resources
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Surveyors found that pureed cabbage served to multiple residents on pureed or mechanical soft diets was prepared with all of the cooking liquid instead of draining excess water as required by the facility’s recipe, then held on a steam table until service. Despite adding thickener and reblending, the pureed cabbage remained runny, spread across the plate, and did not hold its shape when portioned, which the district manager acknowledged was an inappropriate consistency and not in accordance with the facility’s therapeutic diet procedures.
A resident with Alzheimer’s disease and HTN, dependent on staff for eating and ordered a mechanical soft diet, was not provided food in the required mechanically altered form. Staff interviews indicated that kitchen staff were serving regular food or food cut into large pieces instead of properly prepared mechanical soft meals. During observation, the resident’s meal ticket correctly showed a mechanical soft diet, but the tray contained a hamburger cut into large pieces on a full-size bun, which staff acknowledged was not appropriate or safe for a mechanical soft diet.
The facility failed to ensure puree food was prepared to the correct smooth, pudding-like consistency for several residents with dysphagia, malnutrition, neurologic conditions, and dementia who had orders for puree diets. A dietary staff member was observed pureeing breaded salmon patties with broth in a mixer, wiping the sides with a gloved hand, scraping food from the glove back into the mixer, and then using the same glove to handle a broth container. The puree remained with visible chunks of salmon and breading and did not meet the facility’s stated standard of mashed potato or pudding-like consistency, despite the staff member acknowledging the presence of distinct pieces and proceeding with the product as the final puree.
A resident with dementia, dysphagia, and multiple comorbidities had physician orders and care plans for a high-protein, pureed diet with nectar-thick liquids and direct 1:1 supervision during intake, including small bites and controlled pacing. Despite this, a CNA provided the resident a whole banana that did not match the ordered pureed texture and was given without required direct supervision by the speech therapist. Staff interviews and statements indicated the CNA had a pattern of requesting or giving food items not listed on meal tickets or consistent with diet orders, while the speech therapist denied authorizing unsupervised provision of such foods and did not assess the resident after the incident. Review of the record showed no respiratory assessment was documented after the resident received the wrong food texture, contrary to the facility’s dysphagia policy requiring adherence to written diet and fluid consistency orders.
A resident with severe cognitive impairment and multiple comorbidities, including dementia, COPD, and a history of failure to thrive, had an order and care plan for a mechanically altered diet with supervision. During a lunch meal, the resident was served mechanically altered meatballs along with unaltered green beans and whole grapes and was observed eating the grapes alone in the room without staff supervision. An LPN and another staff member confirmed the resident’s mechanically altered diet order and acknowledged that whole grapes are not appropriate for such a diet and should not have been served, while facility policy assigned responsibility to food and nutrition services to prepare and serve the correct food consistency as ordered.
The facility failed to follow prescribed diet textures and liquid consistencies for three residents with chewing and swallowing needs. A resident ordered a mechanical soft diet with chopped meats was served regular Salisbury steak despite a tray card specifying chopped meat. Another resident with dysphagia and an order for honey-thick liquids received unthickened water and Kool-Aid until an RN rechecked the orders and thickened the drinks. A third resident with dementia, dysphagia, and no lower teeth, ordered a mechanical soft diet with ground meats, was served regular Salisbury steak instead of ground meat. The DON and dietary manager confirmed that the foods and liquids provided did not match the ordered mechanical soft, chopped, ground, and honey-thick specifications outlined in facility procedures.
Improper Preparation and Consistency of Pureed Cabbage
Penalty
Summary
The facility failed to ensure pureed foods were prepared in accordance with individual needs and facility recipes, specifically in the preparation of pureed cabbage served at one lunch meal to 22 residents on pureed or mechanical soft diets. During observation of the puree preparation, a staff member removed cooked cabbage from the oven, measured its temperature at 205.2°F, and portioned 33 four-ounce servings of cabbage along with all of the cooking liquid into a food processor. Over the course of the preparation, the staff member added four tablespoons of thickener and reblended the mixture multiple times before placing the pureed cabbage into a steamer for hot holding. The facility’s written recipe for braised cabbage directed that excess water be drained off before pureeing, but this step was not followed. Subsequent observations during trayline service showed that the pureed cabbage, held on the steam table, had a runny consistency that spread across the plate and did not hold its shape when scooped with a #8 scoop. Food temperatures taken before service showed the pureed cabbage at 181°F. The district manager confirmed that residents on pureed or mechanical soft diets received this pureed cabbage and acknowledged that the consistency observed on the plates was not appropriate. A test tray sampled later the same day showed the pureed cabbage remained runny and had broken down while on the steam table, losing some of its consistency. Review of the facility’s therapeutic diet policy indicated that diets are to be prepared according to the approved diet manual and individualized care plans, and review of the cabbage recipe confirmed that draining excess water was required but had not been done.
Failure to Provide Ordered Mechanical Soft Diet
Penalty
Summary
The deficiency involves the facility’s failure to provide food in a mechanically altered form as ordered for a resident who required a mechanical soft diet. The resident was admitted with diagnoses including Alzheimer’s disease and hypertension, and a quarterly MDS assessment documented that she was dependent on staff for eating and required a mechanically altered diet. An undated facility list of residents needing mechanically altered diets also identified her as requiring a mechanical soft diet. Despite these documented needs, staff interviews revealed that the kitchen was cutting food into large pieces rather than preparing it in an appropriate mechanical soft form. A CNA reported that mechanical soft food should be small, but the kitchen was only cutting food into large pieces, and another CNA stated that kitchen staff were providing regular food to residents who required a mechanical soft diet, including this resident. During an observation of the resident’s supper tray, the meal ticket correctly indicated a mechanical soft diet, but the tray contained a hamburger cut into large pieces and placed on a full-size bun. The CNA present at the time of observation confirmed that this was not appropriate for a mechanical soft diet and stated that the hamburger in large pieces on the tray would not be safe for the resident to consume. This noncompliance was investigated under a specific complaint number and affected one of three residents reviewed for appropriate diets, with 13 residents in the facility identified as requiring mechanically altered diets.
Improper Preparation and Consistency of Puree Diets
Penalty
Summary
The deficiency involves the facility’s failure to provide puree food in the correct consistency for multiple residents with physician orders for puree diets. Six residents with diagnoses including cerebral infarction, respiratory failure, protein malnutrition, dysphagia, Parkinson’s disease, hemiplegia, hemiparesis, Alzheimer’s disease, dementia, malnutrition, heart disease, failure to thrive, pulmonary disease, and vascular disease were ordered puree texture food. Their cognitive status ranged from intact to impaired, as reflected by BIMS scores from 0 to 15. Facility policy for puree diets, dated 2022, specified that this diet is for residents who cannot chew or have difficulty swallowing and that the sides of the blender shall be scraped and processed until the food is smooth like pudding. During an observation and interview with a dietary staff member, the surveyor observed the preparation of puree food for residents on puree diets. The staff member placed three breaded salmon patties into a roboku mixer and added chicken broth one spoonful at a time, for a total of eight spoonfuls, then added additional unmeasured broth. On three occasions, the staff member wiped the sides of the mixer with a gloved hand, scraped the food from the glove onto the edge of the mixer, and then, with the same gloved hand, grabbed a jar of broth to add more liquid. Several chunks of salmon and breading remained visible on the sides of the mixer and were not fully mixed back in. The completed puree, when taste tested, was found to contain small chunks and distinct pieces rather than the intended mashed potato or pudding-like consistency. The dietary staff member acknowledged that the mixture contained chunks and distinct pieces and stated it was the best consistency they were going to achieve, despite the facility policy requiring a smooth, pudding-like texture.
Failure to Follow Ordered Pureed Diet and Supervision Requirements for Dysphagic Resident
Penalty
Summary
The facility failed to ensure that food items were provided according to physician-ordered diet textures for a resident with dysphagia and severe cognitive impairment. The resident had multiple diagnoses including hemiplegia, dementia, type 2 diabetes mellitus, chronic kidney disease, and dysphagia, and was care planned for a high-protein, pureed diet with nectar-thick liquids, along with direct 1:1 supervision, small bites, slowed rate of intake, and alternating food and fluids every few bites. Physician orders specified a high-protein, pureed texture diet with nectar consistency and direct one-to-one supervision during intake due to a history of suspected aspiration/penetration episodes. Despite these orders and care plan interventions, a CNA provided the resident with a whole banana, which did not conform to the ordered pureed texture and was given without the required direct supervision by the speech therapist. Multiple staff statements and interviews confirmed that the CNA had a pattern of serving residents food items not consistent with their diet orders and that she had given this resident a whole banana. The CNA reported she believed she had approval from the speech therapist to provide such items if the resident was awake and alert, but the speech therapist denied ever authorizing the resident to receive a banana without his direct supervision. The speech therapist acknowledged he did not assess the resident after learning of the incident and only reported it to a nursing supervisor. Further review of the medical record and nursing documentation showed there was no respiratory assessment completed for the resident after receiving the incorrect food texture. The facility’s dysphagia policy required food service and nursing staff to follow written diet and fluid consistency orders, but this was not followed in this case.
Mechanically Altered Diet Order Not Followed for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that food was prepared and served in a form designed to meet an individual resident’s ordered mechanically altered diet. One resident with an admission date of 05/17/22 had diagnoses including vascular dementia (moderate) with behavioral disturbance, COPD, essential hypertension, and adult failure to thrive. A physician’s order dated 01/13/25 directed that this resident receive a regular diet with mechanical soft texture and regular consistency, with regular texture food/snacks as desired and with supervision. The care plan dated 06/09/25 identified the resident as being at risk for malnutrition/alteration in nutritional status related to dementia with behaviors, history of failure to thrive, depression/anxiety, diabetes, COPD, and cerebrovascular accident, and documented that the resident was to receive a mechanically altered diet and snacks with supervision. An Annual MDS dated 12/04/25 showed the resident had severe cognitive impairment. During a meal service observation on 01/06/26 at 12:24 P.M., the resident was served mechanically altered meatballs, unaltered green beans, and whole grapes. The resident was observed eating the grapes whole while alone in the room, without staff present to provide supervision. At 12:25 P.M., an LPN confirmed the resident was ordered to receive a mechanically altered meal and verified that whole grapes are not considered mechanically altered. At 12:40 P.M., another staff member confirmed the resident’s mechanically altered diet order and stated that whole grapes should not have been served to any resident on a mechanically altered diet due to whole grapes being a choke risk. Review of the facility’s 2021 “Texture and Consistency-Modified Diets” policy indicated that a physician order is required for a modified diet and that the food and nutrition services department is responsible for preparing and serving the correct food consistency as ordered.
Failure to Provide Prescribed Altered Diet Textures and Thickened Liquids
Penalty
Summary
The facility failed to provide food and liquids in the prescribed texture and consistency for three residents who required altered diets for chewing or swallowing needs. One resident with diabetes, hypertension, and COPD had a physician’s order and dietitian assessment specifying a mechanical soft diet with chopped meats. Despite a diet card indicating chopped meat, this resident was served a regular consistency Salisbury baked steak that had not been chopped, and she began eating the meat in its regular form. The DON confirmed the meat should have been chopped, and later explained this was necessary because the resident refused to wear her dentures. Another resident with Kufor-Rakeb Syndrome and dysphagia had a hospital discharge summary and physician’s order requiring honey-thick liquids based on a prior modified barium swallow. This resident, who had moderately impaired cognition, was observed receiving unthickened water and Kool-Aid. An RN initially believed the thickened liquid order had been discontinued but, upon checking the physician’s orders, confirmed that honey-thick liquids were still required and then thickened the drinks. A third resident with dementia, dysphagia, and no lower teeth had a physician’s order for a mechanical soft diet with ground meats and a care plan noting swallowing risk and partial denture use. This resident was observed receiving a regular consistency Salisbury baked steak instead of ground meat. The DON confirmed the meat was not ground as ordered. The dietary manager described facility procedures for chopped and ground meats, and the written procedure stated that diets are to be modified in texture and individualized based on chewing and swallowing ability.
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