Failure to Follow Physician-Ordered Cut-Up Diet Leads to Fatal Aspiration Event
Summary
The deficiency involves the facility’s failure to follow a physician-ordered diet specifying that a resident’s food be cut into bite-sized pieces, and to ensure that this requirement was consistently communicated and implemented by nursing and dietary staff. Resident #9 had multiple diagnoses including heart failure, chronic atrial fibrillation, chronic kidney disease, and moderate vascular dementia with anxiety. A physician order dated December 23, 2024, prescribed a regular diet with regular texture, thin liquids, and explicitly directed that food be cut into bite-sized pieces with large protein portions. The facility’s nutrition care plan initiated on December 30, 2024, referenced the regular diet with large protein portions but did not include the requirement to cut food into bite-sized pieces. The cognition and ADL care plans addressed cognitive impairment and self-care deficits but did not incorporate the ordered cut-up diet or any specific swallowing precautions, despite the resident’s cognitive impairment and upper extremity limitations documented on the MDS. The dietary management and electronic systems in use contained the cut-up order, but this information was not reliably translated into practice. The Menu Wizard tray card history, as reviewed by the senior menu specialist, showed a diet order of regular, regular, thin liquids with notes to cut food into bite-sized pieces and provide large protein portions, and this instruction had been in place since December 23, 2024. The dietary manager stated that dietary staff are responsible for cutting food and that bite-sized pieces would include items like burritos, with food expected to arrive on the unit already cut. However, he also indicated he could not retrieve prior diet slips after discharge and relied on nursing to relay changes. The DON asserted that the “cut into bite-sized pieces” language was a preference rather than part of the actual diet order and stated that only the basic diet components (regular texture, thin liquids) transfer to the kitchen, while additional information such as cutting food does not cross over. In contrast, the prescribing physician confirmed that he ordered regular food, thin liquids, cut into bite-sized pieces, and large protein portions as a single diet order and expected the entire order, including cutting food into bite-sized pieces, to be followed. On the day of the choking event, breakfast trays were delivered to Resident #9’s room, and the resident was served an egg burrito, oatmeal, and cranberry juice. CNA staff reported that the burrito was cut in half but not further cut into bite-sized pieces, and CNA #6 stated she did not know the resident’s diet, did not recall reviewing the meal ticket, and believed his meals did not need to be cut up. She also stated she was unaware of any special instructions to cut the resident’s food into bite-sized pieces and that she typically relied on dietary and nursing to communicate such needs. Multiple CNAs and the charge nurse indicated they were not aware of any formal special diet instructions beyond a regular diet, although the charge nurse acknowledged knowing the family’s preference for cut-up food and finger foods and that dietary did not always cut up his meals, requiring nursing to do so. The resident’s family member reported repeated concerns to the dietary manager, charge nurse, DON, and CNAs about the resident’s food not being cut up, and stated that both she and a hired companion frequently found his meals served uncut despite his upper extremity weakness and motor decline. Later that morning, an LPN who had just started her shift and was not familiar with the resident found him in bed with his breakfast tray in front of him, food apparently eaten, and “mushy” food around and in his mouth. The resident appeared to be sleeping, did not respond to his name, and was grunting and moaning with snoring-type respirations. The LPN manually removed food from his mouth and began suctioning, and the charge nurse arrived with a suction machine and a LifeVac device. Staff observed egg on the resident’s chest and in his mouth, and suctioning removed egg and mucus secretions. EMS was called, and the resident was transported to the hospital. Hospital emergency department documentation recorded that the resident had been eating eggs, was later found choking and unresponsive, and presented with aspiration into the airway and respiratory failure with hypoxia and hypercapnia. The resident was documented as DNR/DNI and was ultimately pronounced deceased. The survey findings attribute this event to the facility’s failure to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and implemented by staff. The report also notes that for Resident #9 there were no active orders for PT/OT/ST evaluation or treatment on the Order Summary Report despite a NP/PA progress note planning for such services, and that the SLP evaluation focused on cognition and compensatory strategies rather than swallowing, with no active speech therapy orders in the diet context. Staff interviews revealed inconsistent understanding of the resident’s diet requirements, with some staff describing cut-up food and finger foods as a preference rather than an order, and others stating they had no knowledge of any special diet instructions. The grievance logs contained no formal grievances from the family member despite her statements that she had repeatedly complained about meals not being cut up and about the resident not being taken to the dining room as he preferred. Collectively, these documented actions and inactions show that the facility did not ensure the physician-ordered diet specifying cut-up, bite-sized food was integrated into the care plan, reliably communicated to dietary and direct care staff, or consistently implemented at the bedside for Resident #9, culminating in a choking and aspiration event requiring hospitalization and resulting in death.
Penalty
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A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
A resident with morbid obesity, chronic respiratory failure, and dependence for ADLs fell out of bed during incontinent care and later returned from the ED with a diagnosed right‑leg contusion. On readmission, nursing staff documented the right lower extremity as red, shiny, and draining, but did not perform a wound assessment, obtain measurements, evaluate the drainage, initiate treatment, or notify the physician, and subsequent notes over several days omitted any reference to the leg despite escalating clinical concerns and eventual sepsis. After a later hospital stay, staff documented discoloration, then a weeping and black wound on the right calf, while the resident frequently refused hygiene and wound care despite education and NP involvement. A necrotic wound was eventually measured and dressed, and a wound care consult later attributed a large posterior right‑leg wound to the earlier fall, with interviews from the resident, the DON, and LPNs confirming that the leg wound evolved from a hematoma and cellulitis and that required assessments, documentation, and provider notifications were not completed in accordance with facility policy.
A resident with diabetes, PVD, CHF, and chronic non-pressure ulcers to the right heel, midfoot, and bilateral lower extremities did not consistently receive ordered wound treatments, and the facility did not perform required ongoing wound assessments. The care plan and physician orders called for scheduled cleansing, application of triple antibiotic ointment or betadine, and appropriate dressings to multiple wound sites, along with weekly documentation of wound measurements and characteristics. Review of the TAR showed several missed and undocumented treatments, and there was no evidence of facility-completed wound monitoring or skin/wound grids for several weeks, despite multiple prior visits to an outside wound clinic. Facility leadership confirmed the absence of wound assessment documentation and the missing treatment initials on the TAR.
A resident with severe cognitive impairment, multiple comorbidities, and total dependence for ADLs was identified as at risk for pressure ulcers and required regular skin assessments and incontinence care. A skin tear on the resident’s right hip, believed to be caused by scratching, was documented and initially cleansed and dressed, but the TAR showed no ongoing wound treatments in place or completed for several days. During this period without documented treatment, subsequent skin evaluations showed the wound on the right trochanter/hip had increased in size and later exhibited signs of infection, including erythema/edema and warmth. Wound treatments with Dakins, Mesalt, and later Santyl were not initiated and documented until days after the wound was first discovered, and the wound nurse confirmed that no outside wound physician or hospice assessed the wound and that treatments were not started promptly.
A resident with a right hip fracture repair was admitted with a surgical dressing and an orthopedic plan for follow-up care. An orthopedic provider phoned in orders to an LPN Unit Manager that included removing the right hip staples on a specified date if the incision was well approximated, and the LPN documented that the staples could be removed on that date. Facility records show the dressing was monitored but the staples were never removed by staff, and instead were taken out later at the surgeon’s office during a follow-up visit. The orthopedic office and the DON confirmed that the order to remove the staples was given and that the staples were not removed as ordered.
Two residents did not receive fully documented skin and wound care as ordered and required by facility policy. One resident admitted with multiple skin issues and a wound vac had admission nursing evaluations that noted the need for wound care but lacked comprehensive skin assessments, including missing wound locations, descriptions, and measurements, despite later documentation of a surgical wound to the right trochanter. Another resident with vascular disease, diabetes, CHF, and a left AKA had multiple wounds and a wound vac, with physician orders for specific nightly wound treatments and scheduled wound vac dressing changes and settings; however, the March TAR showed missing entries for wound care and wound vac management on several dates, and the DON confirmed there was no documentation that these treatments were completed.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Failure to Assess and Treat New Right‑Leg Wound After Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and thorough assessment, monitoring, treatment, and physician notification for a resident’s new right‑leg condition following a fall-related injury. The resident, who was cognitively intact, morbidly obese with a very high BMI, dependent for ADLs and bed mobility, and at risk for falls and skin integrity issues, fell out of bed during incontinent care provided by one CNA. Initial facility documentation on the day of the fall noted no visible injuries, but later that day the resident reported right‑leg pain, portable x‑rays could not be completed due to pain, and she was transferred to the hospital. The hospital identified significant right‑leg pain and diagnosed a contusion of the right lower extremity without fracture before discharging her back to the facility. When the resident returned to the facility in the early morning hours after the hospital visit, nursing documentation described the right lower extremity as red and shiny with moderate drainage. Despite this documented change, there was no wound assessment, no measurements, no description of wound size or characteristics, no evaluation of the drainage, no monitoring parameters, no treatment orders, and no physician notification. From the following day through several subsequent days, progress notes reflected increasing clinical concerns such as pain, confusion, abnormal oxygen saturations, and multiple lab and diagnostic orders, but there was no further mention or documentation of the right‑leg redness or any focused assessment of the leg, even though the earlier finding had been recorded. During this period, the resident ultimately required transfer to the hospital and ICU admission for sepsis, but the facility records did not connect or document the right‑leg condition as part of the ongoing assessment. After the resident later returned from the hospital, staff documented discoloration of the right lower extremity and, the next day, noted a weeping area on the inner right calf and a black weeping wound under the right calf. The resident repeatedly refused measurement and dressing of the wound and refused hygiene and some care despite education on the importance of wound care and hygiene; the NP was notified of her refusals. Later that same day, staff documented a necrotic area on the right lower extremity measuring 5.5 cm by 7.5 cm by 0.1 cm, which was cleansed and dressed, and a care plan was created for an actual skin impairment to the right lower leg. A subsequent wound care consultation identified a posterior right lower extremity wound, attributed to the earlier fall, measuring 9.1 cm by 10.1 cm with undetermined depth. Interviews with the resident and staff confirmed that the leg wound developed after the fall and that there had been no skin assessments, follow‑up documentation, or physician notification regarding the right lower extremity when the red, swollen, draining area was first documented after readmission. The facility’s own pressure injury prevention and management policy required systematic identification, assessment, documentation, treatment, monitoring, and provider notification for all skin integrity concerns, including new wounds and changes in condition, but these steps were not carried out for this resident’s right‑leg condition. The deficiency resulted in the worsening of the untreated right‑leg condition, which progressed to an open necrotic wound requiring hospitalization, surgical debridement, and treatment for sepsis. The resident reported that she had been pushed out of bed during care, injured her leg, and that the wound was not healing, leaving her at risk of losing her leg. Facility nursing leadership and LPNs acknowledged that the leg wound began as a hematoma and cellulitis after the fall, that it became necrotic and required debridement, and that there had been no proper assessment, monitoring, treatment, or documentation of the right lower extremity when the red, swollen, draining area was first observed after the resident’s return from the hospital. They also confirmed that the skin issue was not the focus of care at that time and that the facility did not follow its own policy requiring prompt and systematic management of new skin integrity concerns.
Failure to Complete Ordered Wound Treatments and Ongoing Wound Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide wound treatments according to physician orders and to conduct ongoing assessments of non-pressure wounds for a resident with multiple chronic conditions. The resident was admitted with diagnoses including Type II diabetes mellitus with foot ulcers, CHF, hypertension, PVD, and non-pressure chronic ulcers of the right heel and midfoot. The care plan, revised in April 2026, required detailed and ongoing wound assessments, including documentation of wound location, drainage, peri-wound condition, pain, edema, size, depth, tissue type, exudate, granulation, infection, necrosis, gangrene, and weekly measurements of each area of skin breakdown. Physician orders in February 2026 directed specific wound care to the right heel and bilateral lower leg wounds on scheduled days, and April 2026 orders required daily betadine treatment and bandage to the right fourth toe until healed. Review of the Treatment Administration Records showed missing documentation indicating that ordered treatments were not completed on multiple specified dates for the right heel, bilateral lower legs, and right fourth toe. Additionally, although the resident was followed by a community wound clinic with multiple visits between December 2025 and March 2026, the facility’s own records contained no evidence of wound monitoring or completion of required skin and wound grids from the last wound clinic visit on March 11, 2026, through April 28, 2026. Interviews with the Regional Clinical Nurse and the DON confirmed that no facility wound grids were completed beyond those from the wound clinic and verified the missing initials on the TAR, indicating the treatments were not done. These failures were inconsistent with the facility’s policies requiring weekly pressure and non-pressure wound grids and ongoing assessment to monitor the effectiveness of wound treatments.
Failure to Implement Timely Wound Treatment for Hip Skin Tear
Penalty
Summary
The deficiency involves the facility’s failure to implement timely wound treatment according to physician orders and the resident’s care plan. A resident with Parkinson’s disease with dyskinesia, dementia, CHF, dysphagia, and adult failure to thrive was care planned as being at risk for pressure ulcer development, with interventions including turning/repositioning, incontinence care, and weekly skin assessments. The quarterly MDS documented severe cognitive impairment and total dependence on staff for toileting, hygiene, bathing, rolling, and bed mobility, with the resident always incontinent of bowel and bladder and no skin concerns noted at that time. A skin tear/laceration form later documented a skin tear on the resident’s right hip, believed to be caused by the resident scratching, which was cleansed and dressed per physician order, with a note to trim the resident’s nails. However, review of the TAR for that month showed no wound treatments in place or completed for the right hip/trochanter. A subsequent skin issues evaluation showed the right trochanter/hip abrasion had deteriorated in size, though the dressing was intact. Wound treatment with Dakins wound cleanser, Mesalt, and a dry dressing was not initiated until several days after the wound was first discovered, and was then documented as completed daily. A later skin issues evaluation showed further deterioration of the wound with increased size and signs of infection, including erythema/edema and warmth. The treatment was then changed to cleansing with Dakins, followed by Santyl on moistened gauze and a dry dressing. The wound nurse confirmed that the wound was discovered days before any treatment orders were put in place and that neither an outside wound physician nor hospice assessed the wound.
Failure to Timely Remove Surgical Staples per Orthopedic Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely removal of a resident’s right hip/femur surgical staples in accordance with orthopedic orders. The resident was admitted from the hospital with a right cephalomedullary nail and diagnoses including encounter for other orthopedic aftercare and a nondisplaced fracture of the greater trochanter of the right femur with routine healing, as well as bipolar disorder. Hospital documentation indicated a follow-up with orthopedics was planned, and on 03/13/26 there was an order for a right hip silverlon dressing to remain in place until the orthopedic follow-up, with monitoring each shift and physician notification if drainage was noted. On 03/16/26, the orthopedic provider spoke with the LPN Unit Manager and gave new orders, including that the staples could be removed on 03/21/26 if the incision was well approximated, along with other medication and care instructions. The LPN Unit Manager documented these instructions, including that the staples could be removed on 03/21/26 if the incision was well approximated, and noted the resident’s report of increased right upper thigh pain while using the bedside commode. Subsequent documentation, including the Surgical Wound Note and Surgical Wound Care Services form, showed that the resident was admitted with a right hip surgical dressing and that the surgeon ultimately removed the staples at an office visit on 03/25/26. Review of the medication and treatment administration records from 03/16/26 to 04/11/26 showed that staff monitored the dressing but did not remove the staples as ordered for 03/21/26. Telephone interviews with the orthopedic physician’s office confirmed that they had given the order on 03/16/26 to remove the staples on 03/21/26 if the incision was well approximated, and the DON confirmed that the staples were not removed per the orthopedic surgeon’s orders. The facility’s Telephone Orders policy allowed acceptance of verbal telephone orders from each resident’s attending physician, but the order to remove the staples was not carried out as directed.
Failure to Complete Admission Skin Assessments and Follow Wound Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to physician orders and facility policy for skin and wound management. For one resident admitted with multiple skin issues and a wound vac, the nursing admission evaluation documented that the resident was admitted for wound care and had multiple skin issues, but did not include the location, description, or measurements of the wounds. Subsequent documentation showed a surgical wound to the front right trochanter with specific measurements, and later entries alternately indicated no skin issues or that the surgical site was present on admission, but there was no comprehensive admission skin assessment with required details. The DON confirmed that the medical record lacked documentation of comprehensive wound assessments upon both admission dates, despite the expectation that staff complete such assessments including wound location, description, and measurements. A second resident with diagnoses including peripheral vascular disease, diabetes mellitus, congestive heart failure, and a history of left above-knee amputation had multiple wounds documented on a wound assessment, including a surgical site on the right fifth toe, a deep tissue injury pressure ulcer on the right heel, and a surgical site on the left lateral thigh, all present upon readmission. Physician orders directed specific wound care to the right fifth toe surgical site and right heel wound every night shift, and wound vac dressing changes three times weekly, with continuous wound vac therapy at a specified pressure setting to the left AKA bridged to the left lateral thigh. These orders required cleansing with normal saline, application of betadine, appropriate dressings, and verification that the wound vac dressing was sealed and functioning at the ordered setting. Review of the resident’s March Treatment Administration Record revealed missing documentation for ordered wound care to the right fifth toe surgical site and right heel wound on several dates, and no documentation that the wound vac dressing was changed or that the wound vac was properly functioning on additional dates. The DON confirmed that the medical record did not contain documentation to support that the ordered wound care and wound vac management were completed on the identified dates. Facility policies on Pressure Injury Risk Assessment and Prevention of Pressure Injuries required comprehensive skin assessments upon admission and ongoing documentation of skin condition, type of assessment, dates and times of care, and related observations, but the records for these residents did not reflect compliance with those requirements.
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