Failure to Provide Ordered Bite-Sized, High-Protein Diet
Summary
The facility failed to ensure a resident received food prepared and portioned according to physician diet orders and the resident’s identified needs. The resident had diagnoses including epilepsy, dementia, chronic kidney disease, a pressure ulcer, anxiety, major depressive disorder, and dysphagia, and was care planned as at risk for malnutrition and dehydration with a history of unplanned significant weight loss, fluctuating intakes, poor appetite, and multiple episodes of skin breakdown. A physician order dated 02/03/26 required large protein portions at meals and that meats/entrées be cut into bite-sized pieces for wound healing. The care plan interventions included providing meals per physician diet orders, monitoring and evaluating meal intake, and providing feeding and dining assistance as needed. The resident’s MDS showed moderate cognitive impairment and a need for setup/cleanup assistance with eating. During an interview, the resident reported ongoing concerns with the dietary department, stating the kitchen repeatedly “messed up” his food, that it was hard to eat some foods because he did not have teeth, and that despite his stated food preferences being on his meal ticket, he still received the wrong items. Observation of a breakfast meal showed the resident was served a tray with one whole piece of ham, one piece of bread, and a small portion of scrambled eggs. The meal ticket on the tray, highlighted in pink, instructed staff to cut food into bite-sized pieces and provide large protein portions. A CNA confirmed that the ticket specified bite-sized food and large protein portions, but the ham and bread were not cut and the protein portions of ham and eggs were not large. Facility policy defined large portions as one and a half times the standard portion unless otherwise indicated on the meal ticket. This failure to follow the diet order and meal ticket instructions led to the cited deficiency.
Penalty
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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 with dementia and dysphagia had a physician order and care plan for a mechanically soft diet with pureed meats and thin liquids, requiring maximum assistance with eating. During a breakfast observation, the resident was being fed oatmeal, scrambled eggs, and ham that appeared chunky rather than pureed. The CNA confirmed the resident’s meat should be pureed and acknowledged the ham was not in pureed form. Review of facility policy showed pureed foods must have a smooth, lump-free consistency, confirming that the meat served did not meet the ordered diet texture or policy requirements.
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.
A resident with a history of stroke, hemiplegia, dysphagia, and prior aspiration pneumonia was ordered a mechanical soft diet with thin liquids and had documented chewing problems and a need for supervision at meals. Despite this, a CNA who knew of the altered diet order provided a regular-texture ham sandwich as an evening snack and the resident was not supervised while eating. The resident subsequently choked, was found clutching his throat and unable to cough, and multiple staff attempted the Heimlich maneuver without success before the resident became pulseless and CPR was initiated. EMS removed a large piece of meat completely obstructing the trachea, resuscitated the resident, and transferred him to the hospital, where records and the death certificate attributed anoxic brain death, cardiac arrest, and aspiration pneumonia to choking on food.
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.
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.
Failure to Provide Prescribed Pureed Meat Texture for Dysphagic Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide food in the prescribed texture for a resident with dysphagia. The resident was admitted with diagnoses including dementia and dysphagia and had a physician’s order for a regular diet with mechanical soft texture, pureed meats, and thin liquids. The care plan identified nutritional problems related to chronic disease, a mechanically altered diet, malnutrition risk, and the need for supplements, with interventions that included monitoring for signs and symptoms of dysphagia and providing and serving the diet as ordered. A minimum data set assessment documented that the resident’s cognition was severely impaired, she had no swallowing disorder signs and symptoms at that time, and required maximum assistance for eating. During an observation of breakfast service, the resident was seated in a common area and being fed by a CNA. The meal included oatmeal, scrambled eggs, and a bowl of what appeared to be mechanical soft ham. When questioned, the CNA stated the resident was to receive mechanical soft food with pureed meat. Upon further inspection, the CNA acknowledged that the ham appeared chunky rather than pureed and demonstrated a visible chunk with a spoon. The tray was then sent back to request new meat. Policy review showed that pureed foods are to be processed to a pudding or mashed potato consistency with no pieces, lumps, or need for chewing, indicating that the meat served did not meet the facility’s own standards for pureed food or the resident’s ordered diet. This deficiency represents non-compliance investigated under Complaint Number 2740471.
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 Diet Texture and Lack of Meal Supervision Lead to Fatal Choking Event
Penalty
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.
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.
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