Failure to Follow Therapeutic Diet Orders for Residents With Dysphagia and Aspiration Risk
Summary
The deficiency involves the facility’s failure to ensure that therapeutic and modified diets were implemented and served in accordance with physician orders for three residents with dysphagia and high aspiration risk. One resident with dementia, dysphagia, aphasia, and a strict NPO order following a stroke was brought to the dining room after a therapy session, even though she did not normally dine there. The dining assistant, who had not used the available tablet to verify diet orders and believed the resident was someone else, served her a regular textured meal consisting of a ham or turkey sandwich with cheese and juice. The resident’s significant other observed her eating a sandwich and salad, and a staff member then stated she was not supposed to have food. The RN assessed the resident, found her SpO2 at 71%, and she was sent to the ED, where documentation indicated a transient hypoxic episode after being given lunch despite strict NPO status, with concern for an aspiration event. Another resident with multiple sclerosis, mild cognitive impairment, and dysphagia had a physician order for a Level 4 pureed texture diet with thin liquids. Her care plan identified a regular diet with pureed meats and directed staff to serve the diet as ordered. She had a recent history of choking and regurgitation episodes, including an event where she was spitting up food, had wheezing in the lower lung lobes, and required an ED visit with EGD and extraction of a food bolus. Despite this history and the ordered pureed diet, surveyors observed her in the dining room eating a hotdish made from stuffing with chunks of turkey, which dining staff identified as appropriate for a regular or minced and moist diet, not a pureed diet. At the time of observation, dining assistants acknowledged that diet information was available on iPads and diet slips but admitted they sometimes did not use them, and no such tools were in use until prompted by the surveyor. A third resident with dementia, expressive aphasia, and dysphagia had physician orders and a care plan for a Level 4 pureed texture diet with Level 2 mildly thick liquids. The care plan also documented that his family member could provide thin liquids and different textures only when present and that snacks left by the family for use in the resident’s absence were to be compatible with his modified diet. Progress notes documented prior concerns about pocketing food, a choking episode in the dining room where he was not breathing and had turned purple, and subsequent changes to a pureed diet and restrictions on snacks in his room. Despite these orders and documented risks, surveyors observed him independently propelling himself in his wheelchair near the dining room while eating Oreo cookies without staff supervision. The DON later confirmed there was no signed consent for a liberalized diet and that the family member did not want him to have Oreo cookies, and the facility’s own therapeutic diet policy required that snacks be compatible with the therapeutic diet.
Removal Plan
- Review the facility process for ensuring the correct resident receives the correct diet as prescribed by the provider.
- Review and revise care plans for accuracy.
- Educate all staff with competency on resident care plan revisions, the facility procedure for implementing physician-ordered diets, diet textures, and protections from negative outcomes.
- Implement meal tray audits.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with Parkinson’s disease, dysphagia, cognitive impairment, and weight loss had a physician order for a health shake with meals as part of a therapeutic diet. During meal service, the shake was not on the tray and no substitute was offered; staff said the dietary aide forgot it and the LVN missed it when checking trays, while the resident reported he sometimes receives the shake and sometimes does not.
Two residents with complex medical conditions, including diabetes, chronic kidney disease, and dependence on renal dialysis, did not receive their physician-ordered therapeutic diets. One resident ordered for a consistent carbohydrate diet was incorrectly listed and served under a renal diet. Another resident ordered for a liberalized low protein renal diet with mechanical soft texture was served ham instead of the specified ground pork cutlet, contrary to the facility’s renal diet policy that prohibits cured meats. Dietary staff relied on incorrect tickets and substitutions, and the RD reported not conducting tray-line audits or being aware that prescribed diets were not being followed.
Surveyors found that multiple residents with dysphagia, cognitive impairment, and nutritional risk were not receiving physician-ordered fortified and mechanically altered diets. Despite documented orders and tray tickets specifying fortified puddings, super puddings, fortified meal plans, and mighty shakes, residents were observed at meals receiving standard items such as potatoes, fish, hush puppies, and sandwiches without the prescribed fortified components. Meals for these residents appeared identical to regular meals, and staff interviews confirmed that fortified preparations were not consistently provided as ordered.
A resident with DM and end-stage renal disease, whose physician-ordered diet specified a renal CCHO diet with soft and bite-sized texture, regular/thin liquids, and no salt, was served double portions of meat and rice without a corresponding physician order. The dietary staff provided these double portions based on the resident’s request, and the meal ticket reflected double portions contrary to the order. An LPN reported the resident’s blood glucose readings were elevated, and the facility’s own policy required diets to be served exactly as ordered by the physician.
Therapeutic diets were not followed for a resident with hypokalemia who was ordered a regular/liberalized pureed diet. During lunch observation, the resident’s meal ticket indicated a pureed diet, but the resident was served whole Mandarin oranges instead of a pureed dessert, and a CNA confirmed the oranges were not pureed.
A resident with dementia, multiple vitamin deficiencies, and documented dental issues had a physician order for a high‑protein supplement TID with meals and a recorded dislike of chicken. During a lunch meal, the resident was served chicken cordon bleu and did not receive the ordered high‑protein milkshake, even though both the supplement order and the chicken dislike were clearly printed on the diet ticket. The resident reported inconsistent receipt of the milkshakes and reiterated his dislike of chicken, while a CNA, the Dietary Manager, and the DON each confirmed that the meal and supplement provided did not match the documented physician orders and stated food preference.
Therapeutic Diet Supplement Not Provided as Ordered
Penalty
Summary
The facility failed to ensure a therapeutic diet order was carried out for one resident who had Parkinson’s disease, dysphagia, moderate cognitive impairment, dependence for all eating, and documented weight loss. The resident’s record showed a physician order for a health shake with meals as part of a therapeutic diet plan for nutritional support, along with a mechanically altered diet and nectar consistency. The care plan addressed actual weight loss related to diet change and decreased oral intake, with an intervention for diet as ordered. During meal service observation, the resident did not receive the ordered health shake with the lunch tray, and no substitute supplement was offered or provided at that time even though the meal ticket listed the shake. The resident stated he had not received the shake and said he sometimes gets it and sometimes does not. Staff interviews showed the CNA was unaware the shake had not been delivered, the dietary aide said she forgot to put it on the tray, the LVN stated she must have missed it when checking the tray, and the dietary manager said the order was supposed to be followed from the meal tickets. The DON and Administrator both stated the resident was expected to receive the health shake with meals.
Failure to Accurately Implement Physician-Ordered Therapeutic Diets
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered therapeutic diets were accurately implemented for two residents. One resident with bacteremia, osteomyelitis, and type I diabetes mellitus had a care plan intervention to provide the ordered diet and a physician order for a consistent carbohydrate diet with regular texture and thin liquids. However, during a lunch tray-line observation, this resident’s diet ticket incorrectly listed a renal diet. Dietary staff questioned whether the resident should receive ham and collard greens, and the tray was prepared and placed on the cart based on an incorrect renal diet listing. The dietary manager later confirmed that the diet ticket was wrong and that the resident should have been receiving a consistent carbohydrate diet instead of a renal diet. Another resident with chronic kidney disease, dysphagia, polyosteoarthritis, and dependence on renal dialysis had a care plan intervention to provide the ordered diet and physician orders for a liberalized low protein renal diet with low concentrated sweets, mechanical soft texture, and regular thin liquids. During a lunch tray-line observation, this resident’s ticket correctly listed a renal diet with mechanical soft texture, but the resident was served ham after dietary staff confirmed its use, despite the facility’s renal diet spreadsheet indicating that the meal should have included a ground pork cutlet. No ground pork cutlets or ground chicken were prepared. The registered dietitian reported that she did not perform tray-line audits and was unaware that prescribed diets were not being followed. Review of the facility’s Liberalized Low Protein Renal Diet policy showed that cured and canned meats such as ham were prohibited, which conflicted with what was actually served.
Failure to Provide Physician-Ordered Fortified and Therapeutic Diets
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide therapeutic and fortified diets as ordered by physicians for four residents with dysphagia, cognitive impairment, and nutritional risk. Physician orders and meal tickets documented requirements for mechanically altered diets and fortified items such as fortified puddings, super puddings, fortified meal plans, and mighty shakes. However, during meal observations, these ordered fortified components were not provided, and the meals served appeared the same as regular meals without the prescribed enhancements. For one male resident with depression, dysphagia, GERD, hyperlipidemia, hypertension, and dysphagia following cerebral infarction, the MDS showed severe cognitive impairment and pain with swallowing, and he was coded as being on a mechanically altered diet. Physician orders included a regular mechanical soft diet with ground texture and fortified pudding twice daily for malnutrition. His meal ticket reflected a regular diet, mechanical soft diet, and fortified pudding cream. During a lunch observation, he was seen self-feeding potatoes, fish, and hush puppies, with no fortified pudding present, and his meal looked identical to those of residents receiving regular meals. A female resident with Alzheimer’s disease, depression, dysphagia, GERD, hyperlipidemia, and abnormal weight loss had an MDS indicating severe cognitive impairment, pain with swallowing, and a mechanically altered diet. Her physician orders included mighty shake 4 oz twice daily at lunch and dinner and fortified pudding 4 oz twice daily at lunch and dinner, and her meal ticket listed a regular diet, mechanical soft diet, fortified pudding/ice cream, fortified enhanced food, and mighty shake. At a lunch observation, she was self-feeding potatoes, fish, and hush puppies, with no mighty shake, ice cream, or fortified pudding on her tray, and her meal appeared the same as regular meals. Another female resident with anemia, hypertension, renal insufficiency, Alzheimer’s disease, anxiety disorder, depression, dysphagia, and vitamin D deficiency had an MDS showing severe cognitive impairment, pain with swallowing, and a mechanically altered diet. Her physician orders included mighty shake 4 oz twice daily at lunch and dinner and fortified pudding 4 oz twice daily at lunch and dinner, and her meal ticket listed a regular diet, mechanical soft diet, fortified pudding/ice cream, and mighty shake. During a lunch observation, she was self-feeding a cheese sandwich with juice, milk, and water, with no mighty shake, ice cream, or fortified pudding on the tray. A fourth female resident with depression, dysphagia, GERD, hyperlipidemia, hypertension, and diabetes had an MDS indicating severe cognitive impairment and a mechanically altered diet. Her physician orders included a fortified meal plan diet with mechanical soft texture and thin consistency, and super pudding 4 oz twice daily at lunch and dinner. Her meal ticket listed a regular diet, mechanical soft diet, fortified pudding/ice cream, fortified enhanced food, and mighty shake. At a lunch observation, she was self-feeding potatoes, fish, and hush puppies, with no fortified meal plan or fortified pudding present, and her meal looked the same as those of residents receiving regular meals. In interviews, the Dietary Manager stated she usually prepared fortified pudding and sometimes added extra butter and sour cream to potatoes for fortified meals but had not done so that day, and an LVN acknowledged that residents with fortified meal orders were receiving meals that looked like regular meals and that diets were ordered for specific health and safety reasons.
Failure to Follow Physician-Ordered Therapeutic Diet for Diabetic Resident
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by the physician for a resident with diabetes mellitus and end-stage renal disease. The resident’s care plan and physician’s order specified a renal diet with consistent carbohydrate (CCHO), soft and bite-sized texture, regular/thin liquids, and no salt placed on the tray, with no order for double portions. Despite this, observations on the lunch meal service showed the resident received double portions of meatloaf and rice, along with a single portion of green beans and apple juice. The meal ticket for that lunch also reflected double portions, which did not match the physician’s order. During interviews, the Dietary Supervisor acknowledged that the resident did not have an order for double portions and stated that double portions were provided because the resident requested them. The Dietary Supervisor also stated that giving double portions of rice could lead to high blood sugars. A review of blood sugar monitoring for the resident showed readings ranging from 177 mg/dL to 343 mg/dL before dinner during the month, and an LVN reported that normal blood sugar ranges were 70 to 99 mg/dL and that he was unaware the resident was receiving double portions. The facility’s policy on therapeutic diets required that diets be provided consistent with physician orders and served as ordered, but the resident’s diet was not served according to those orders.
Therapeutic Diet Not Followed for a Resident
Penalty
Summary
Therapeutic diets were not provided as prescribed for R #12. R #12 was admitted with a diagnosis of hypokalemia and the MDS indicated a regular/liberalized pureed diet. During lunch observation on 3/26/26 at 11:42 a.m., R #12's lunch ticket showed a pureed diet, but the resident was served whole Mandarin oranges instead of a pureed dessert. CNA #2 confirmed that the Mandarin oranges were whole and not pureed.
Failure to Provide Ordered High-Protein Supplement and Honor Food Dislike
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered high‑protein supplement and to honor a documented food dislike for a resident with multiple nutritional deficiencies and moderate cognitive impairment. The resident’s diagnoses include unspecified dementia with moderate cognitive impairment, vitamin D, E, and ascorbic acid deficiencies, and a disorder of teeth and supporting structures. A dietary physician order dated February 4, 2026, specifies that the resident is to receive a regular high‑protein supplement three times daily with meals at 7:30 a.m., 12:00 p.m., and 5:30 p.m. The same physician order/meal ticket also documents that the resident dislikes chicken. On observation at a lunch meal, the resident was served chicken cordon bleu as the entrée and did not receive the ordered high‑protein milkshake supplement, despite both the supplement and the chicken dislike being clearly documented on the physician order/meal ticket. The resident later stated that he does not like chicken, but ate the entrée because the ham inside made it more tolerable, and reported that he enjoys the high‑protein milkshakes but does not receive them consistently at every meal as ordered. A CNA confirmed that the resident did not receive the high‑protein milkshake and was given chicken in error, acknowledging that both the supplement and the chicken dislike were on the ticket. The Dietary Manager confirmed that chicken was listed as a dislike and that the high‑protein supplement was ordered three times daily, and acknowledged that the kitchen staff missed adding the supplement. The DON also confirmed that the physician order/dietary ticket documented the chicken dislike and the high‑protein milkshake order.
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