HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure Food and Nutrition Services (FNS) department was organized, managed and effectively integrated into the hospital wide organizational structure to ensure consistent collaboration and interaction between different departments within the hospital for sharing of information, resources, and efforts to achieve common goals or solve problems that had the potential to impact patient care when:

1. The facility failed to ensure the facility's diet manual (DM) was developed and implemented in accordance with current national standards for routinely ordered therapeutic dysphagia (difficulty swallowing) diets, and was not consistently used as guidance for ordering and preparing patient diets when the DM guided physician's to order obsolete (out-of-date) dysphagia diets such as "chopped" and "ground" from a no longer recognized National Dysphagia Diet (NDD) system. Clinical Nutrition Manager (CNM) stated the facility's information technology department informed her it was not possible to change the available diet order selections in the electronic health record (EHR) software to align with current standards of practice IDDSI (International Diet Standardization Initiative) dysphagia diet terminology. FNS department was not organized sufficiently when Director of Food and Nutrition Services (DFNS) nor CNM brought system level concerns and barriers to hospital leadership such as Medical Director and/or medical executive staff, and/or patient care policy committee and/or QAPI (Quality Assessment and Performance Improvement) for further discussion and review of standard of practices that warranted a systemic change for the health and safety of patients. (Cross Refer A-0618, A-0631)

2. Although DFNS/Registered Dietitian (RD) and CNM (an RD) provided IDDSI training to FNS staff, the FNS department RD leadership did not ensure sufficient organization into the hospital wide organizational structure when CNM was unaware as to whether the Speech Therapists (ST) or nursing was trained on IDDSI diets. In addition, CNM trained kitchen staff to prepare pureed rice and pureed scrambled eggs for the facility's "chopped" diet (facility's version of IDDSI Soft & Bite Sized diet/SB6 diet) based on one STs recommendation, however, that was not in accordance with the definition of that diet per the hospital's DM. CNM had not discussed the systemic change interdepartmentally to collaborate and discuss whether the change was aligned with standard of practice, or whether additional support and resources was warranted to support development of appropriate recipes and skillset of the cooks to ensure IDDSI standards could be accomplished for improved quality of food service for patients on an SB6 diet . (Cross Refer A-0618, A-0631)

3. The facility failed to ensure FNS department was effectively organized into the hospital wide organizational structure and systems when the FNS policy and procedure (P&P) titled "Fluid Restrictions (FR)" that impacted patient care related to FR orders only required approval within the FNS department by the DFNS. In contrast, the facility's P&P titled "Vital Signs, Intake & Output, Weights: (Adult)" that provided direction to nursing staff on FRs was reviewed and approved interdepartmentally by "Approvers: Medical Executive Committee, Patient Care Policy Approval Committee, Patient Care Policy Committee." As a result, there was unclear direction provided to FNS staff on how menus and foodservice should be incorporated as related to standards of care per Nutrition Care Manual and lack of adequate guidance to the nutrition hosts and diet clerk's who were responsible for checking patient menus for accuracy in accordance with a physician's FR order and had the potential for negative medical complications for patients with a FR order.
(Cross Refer A-0618, A-0621)

Findings:

1. During a concurrent interview and record review on 6/9/25 at 2:05 p.m. with CNM, Patient 5's "Order Desc [OD: description]", dated 2/11/25, was reviewed. The "OD" indicated, "Chopped Diet." CNM stated chopped diet was not an IDDSI (International Dysphagia [difficulty swallowing] Diet Standardization Initiative) diet but "it's our house version for DDS SB6 diet (Level 6 Soft & Bite Sized)." CNM stated the physician's ordered "chopped" and "ground" diet orders in a patient's EHR from a pop down diet selection list in which those diets were available. CNM stated IDDSI diets were not available in the pop down diet list for physician's to select from. CNM stated she asked the hospital's information technology department to discontinue chopped and ground diet orders available from a pop down selection list in the EHR to IDDSI diet terminology to be consistent for standardization in accordance with current standard of practice but was told they could not change diet order options in the EHR. CNM stated she had not pursued the discussion further with hospital leadership such as via Chief Executive Officer, the medical executive or patient policy committee or via the hospital's QAPI (Quality Assessment Performance Improvement) program to provide education on the importance of aligning the hospital's physician prescribed diet orders with the only nationally recognized dysphagia IDDSI diets in accordance with standard of practice.

During review of United States IDDSI Reference Group (USIRG), dated November 2021, USIRG indicated, "IDDSI has the full support of the Academy of Nutrition & Dietetics (AND) and the American Speech-Language & Hearing Association (ASHA) since May 2019. October 2021: IDDSI is now the only professionally recognized dysphagia diet standard in the Nutrition Care Manual of the AND for the United States."

During a review of IDDSI.Org titled "Guidelines For Use" (GFU), dated 2024, "GFU" indicated, "Supplementary Notice: Do not alter the elements of the IDDSI framework. Alterations may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death."

During a review of IDDSI's document titled "Standards of Practice Regulatory Information for Long Term Care Facilities, Hospitals, Critical Access Hospitals, Home Health Agencies and Hospice", dated July 2021, indicated, "The National Dysphagia Diet (NDD) is now outdated and International Dysphagia Diet Standardization Initiative (IDDSI) will be the only professionally recognized texture modified diet framework as of October 2021. . .It is the only professionally- supported and evidence-based standard of practice."

2. During a review of the facility specific diet manual titled, "[name of hospital] Health Diet Manual (DM)", dated 2025, the "DM" indicated, "Dysphagia Diets: The International Dysphagia Diet Standardization Initiative (IDDSI) has become the professional standard for providing dysphagia diets. The goal is to ensure consistent and safe textures for patients with dysphagia. The names of the diet orders in [name of EHR software) have not changed but the interpretation of the diets are as follows: Diet Order: Chopped; interpretation-IDDSI Level 6 Soft & Bite Sized, Ground; IDDSI Level 5 Minced & Moist, Puree; IDDSI Level 4 Pureed, Blenderized; IDDSI Level 3 Liquidized. IDDSI Level 6- Soft & Bite Sized Indication: This diet is prescribed when patients are unable to safely bite off pieces of food but are able to chew the food into smaller pieces that can be safely swallowed. . .Food pieces should be no larger than 1.5 cm [centimeter] x [by] 1.5 cm (or the width of a dinner fork). Foods should be soft, tender and moist, for easier chewing and swallowing. Foods where sauce separates from the food should be strained or blended to ensure one consistency. Moisten foods with small amounts of gravy, sauce, juice or cooking liquids-but only if it can be absorbed into the food and does not separate. Food Groups. . .Protein - foods allowed: Cooked and soft proteins that are not on the restricted list, Foods Restricted: Poultry or fish with skin and/or bones, Natural casing on sausages, Breads and starches - foods allowed: Soft foods not on the restricted list, Foods Restricted: Crackers, biscuits, muffins, pancakes, waffles, bread dressing, sticky rice or rice that separates into individual grains. . ."

During a concurrent observation and document review on 6/9/25 at 11:11 a.m. in the kitchen during lunch trayline (where prepared meals are assembled onto trays ), Patient 5's lunch meal tray card indicated, "Diet: Chopped; Clerk Check [extra check process for meal tray accuracy]", dated 6/9/25. Patient 5's lunch meal tray was observed to have chopped chicken stirfry, pureed rice that was observed with liquid pooled on top with liquid separation coming out from the side of the thin appearing pureed rice that spread out on the plate, and a cup of gravy that had liquid separation.

During an interview on 6/9/25 at 1:59 p.m. with CNM, CNM stated the kitchen staff always served pureed rice and pureed scrambled eggs for all "Chopped" (hospital's version of SB6 diet) and "Ground" diets (hospital's version of Level 5 Minced & Moist [MM5] diet). CNM stated there should not have been any liquid separation from the pureed rice or gravy served for the "chopped" diet, as that was not allowed per IDDSI SB6 diet standardization. CNM stated the hospital served pureed rice and pureed scrambled eggs for all "chopped" and "ground" diets across the board and was not dependent on patient-specific dysphagia assessment by an ST (Speech Therapist). CNM stated a ST that used to work at the hospital had told the FNS department to serve those food items in a pureed texture for the chopped and ground diet for patient safety. CNM was unable to provide documentation of that communication and/or the name of the previously employed ST or anyone else whom approved that to be implemented hospital wide without being based on an individualized ST assessment to demonstrate the required need for patient-specific safety.

During a review of IDDSI.org, dated 2025, IDDSI indicated, "The risks associated with swallowing a mixed consistency item [such as when liquid separates out from a solid] are as follows:The liquid component of the item may separate and spill into the pharynx (throat) during oral preparation of the bolus (a mass of chewed food). This may represent an increased aspiration risk (when food or liquid enters the lungs instead of going down the esophagus/throat that could lead to health problems) in people with dysphagia. Solid particles may be washed into the pharynx with the liquid component, before they have been adequately chewed. If these particles enter the airway, there is an increased risk of choking and airway obstruction."

During a review of NCM under title, "IDDSI Level 6 Soft and Bite-Sized Nutrition Therapy (SB6 diet)", dated 2022, the NCM for SB6 diet indicated, "Foods Recommended: Couscous, quinoa, or rice held together with smooth, thick sauce that keeps rice from separating into individual grains, Foods Not Recommended: Grainy, sticky, or glutinous rice. . .Level 6 Soft & Bite Sized Sample 1-Day Menu: Breakfast: 1 scrambled egg cut into 1.5 cm x 1.5 cm pieces."

During a review of IDDSI.org under "Frequently Asked Questions", dated 2025, IDDSI indicated, "The average tracheal (a tube in the neck and chest that carries air to and from the lungs) size for adult males is 22 mm (millimeters) and for adult females is 17 mm (Brodsky et al., 1996). Particle sizes of 15 mm (i.e. 1.5cm) size are therefore more likely to pass through the trachea, than block it."

During an interview on 6/10/25 at 3:20 p.m. with ST, ST stated she was aware the kitchen provided pureed rice and pureed scrambled eggs for the chopped diet orders which was in place when she began working at the hospital 3 1/2 (three and a half) years ago. ST stated she did find that practice to be unusual and did question it but never received an answer that made sense and did not pursue it further.

During a review of the facility's planned "Chopped" menu that repeated every seven days, dated 6/9/25, the non-select chopped menu indicated pureed scrambled eggs were provided 7 out of 7 days, and pureed rice was provided for six meals during the weekly menu cycle.

During a review of the facility's DM, dated 2025, the DM for chopped and/or Soft & Bite Sized (SB6) diet provided no indication that pureed scrambled eggs or pureed rice was approved to be provided on an IDDSI SB6 diet.

During a concurrent interview and record review on 6/10/25 at 3:30 p.m. with ST, Patient 5's "Speech Therapy Forms (STF)", dated 2/3/25 was reviewed. The "STF" indicated, "Recommendations: 1. chopped diet with thin liquids, 2. Strategies: 1:1 feeding assistance, upright with PO intake, single sips of liquid, slow rate, 3. oral care 3x daily, 4. ST for dysphagia management" signed by ST 2. ST was asked if she was aware that IDDSI was the only recognized dysphagia diets, and that "chopped" and "ground" diets was from an obsolete National Dysphagia Diet (NDD), and ST stated, yes. ST stated the ST's at the hospital performed dysphagia tests, treatment and recommended dysphagia diets to physician's for patients. ST stated ST's provided recommendations on diet textures such as "chopped" and "ground" although she was aware it was an outdated term, but that was what the hospital used. ST was not able to explain why the hospital used out of date dysphagia diet terminology that was no longer nationally recognized. Further, ST stated she had not received training on IDDSI diets.

During a review of "Patient List Chopped Diet (PLCD)", dated 6/10/25, the "PLCD" indicated there were 8 additional patients prescribed a "chopped" diet (Patient's 6, 7, 8, 9, 10, 11, 12, 13). Of those chopped diet orders, five specified thin liquids, and three had no liquid consistency specified.

During a review of the facility's DM, dated 2025, the DM indicated, "Due to the pathophysiology of dysphagia, the IDDSI framework requires that the liquid consistency be clarified by the physician and/or speech therapy prior to sending liquids to drink to the patient. Assumption that the patient can tolerate thin liquid cannot be made. Therefore, if the liquid consistency is not included with the diet order, the FNS department will not provide fluids to drink. It is highly encouraged prescribing physician to include liquid consistency in the diet order for safety and patient satisfaction with meals provided."

During an interview on 6/10/25 at 3:48 p.m. with CNM, CNM stated she had trained FNS staff on IDDSI diets and provided training to medical staff during a meeting a while back. CNM stated she did not know if STs or nursing received IDDSI training.

During an interview on 6/10/25 at 4:40 p.m. with Director of Rehabilitation (DOR), DOR stated she was responsible for oversight of the rehabilitation department which included the STs. DOR stated she was aware the hospital fully transitioned to IDDSI at the end of year 2021. DOR stated at that time, the STs had received training on IDDSI diets, however, none of those STs were still employed at the hospital and the STs hired since then had not received IDDSI training.

During a review of the facility's job description (JD) titled, "Speech Pathologist (ST)", dated 11/15/24, the JD indicated, "The Speech Pathologist assesses, treats, and helps to prevent disorders related to speech, language, cognitive-communication, voice, and swallowing problems. . .Job Responsibilities: Participates in continuing education to remain current in new treatment procedures, active in providing in-services to departmental staff."

During a review of the facility's JD titled, "Clinical Nutrition Manager (CNM)", dated 10/23/23, the "JD" indicated, "Identifies, reviews, and evaluates nutrition services through quality assurance and monitoring techniques to improve quality of care. Serves as a resource person to dietitians, physicians, house staff, nursing services, and food service personnel regarding clinical nutrition practices, development and trends. Approves nutritional adequacy of menus and writes special diet menus. While developing menus collaborates with purchasing, production, and patient service area. Collaborates on recipe development and views product evaluation with all necessary members of the department and hospital. Evaluates conformance to quality standards and diet orders. . .Serves as a liaison between nursing, medical personnel and other allied health personnel in relation to clinical nutrition. . .Additional: Upon request, plans and implements in-service training for physicians and nursing personnel."

During a review of the facility's JD titled, "Director of Food & Nutrition Services", dated 10/23/23, the JD indicated, "Oversees both the food service program as well as the clinical nutrition program. . ., Provides oversight of the clinical nutrition program. Provides guidance and direction to the Clinical Nutrition Manager."


During review of the NCM, dated 2022, the NCM indicated, "Treatment of dysphagia encompasses a multidisciplinary approach. Physicians and speech-language pathologists (SLPs) evaluate individuals with dysphagia through various procedures. The SLP may prescribe a texture-modified diet for foods and/or fluids and muscle-strengthening exercises and postural [sitting positions] maneuvers to increase swallow safety. The RDN supports the individual with dysphagia by encouraging adherence to texture-modified diet recommendations and recommending acceptable foods and fluids that meet the prescribed diet and nutrient needs. . .Often the entire health care team (including physicians and nurses) is involved in monitoring patients for difficulties related to chew/swallow; in reporting concerns per facility policy; monitoring diet texture effectiveness, adherence, and understanding; and evaluating needs related to patient education. . .The National Dysphagia Diet (NDD) and associated resources will no longer be included in the NCM after October 2021."

During review of United States IDDSI Reference Group (USIRG), dated November 2021, USIRG indicated, "IDDSI has the full support of the Academy of Nutrition & Dietetics (AND) and the American Speech-Language & Hearing Association (ASHA) since May 2019. October 2021: IDDSI is now the only professionally recognized dysphagia diet standard in the Nutrition Care Manual of the AND for the United States."

3. During an observation on 6/9/25 at 10:17 a.m. during patients lunch trayline (an assembly line system where prepared food items are placed on trays) in the kitchen, Patient 1's lunch meal tray had a meal tray card that indicated, "Diet: FR [fluid restriction] 1500 [ml: milliliters of fluid a (per) day was the maximum amount of fluids patient could consume in 24 hours]. . . Renal [diet for kidney disease], 60 g [grams] CC [carbohydrate per meal to manage diabetes]. . ." Patient 1's lunch meal tray was observed with 8 ounces (oz.) of iced tea, a 4 oz. container of applesauce and 1/2 (half) a cup of diced peaches in a serving dish with a lid on it.

During an observation on 6/9/25 at 10:27 a.m. during patients lunch trayline in the kitchen, Patient 2's lunch meal tray had a meal tray card that indicated, "Diet: Renal, Dry Tray." Patient 2's lunch meal tray included a container of light & fit yogurt and a 4 oz. container of apple sauce.

During a concurrent interview and record review on 6/9/25 at 2:21 p.m. with Clinical Nutrition Manager (CNM), Patient 2's diet order in the electronic health record (EHR) was reviewed. CNM stated Patient 2's diet order was a renal diet with a 1,200 ml FR per day. CNM used a software program (SP) utilized by FNS department that included specific foods and beverages provided to each patient on a meal tray. CNM stated the SP indicated Patient 2 was on a 1,200 ml FR. CNM stated the SP indicated Patient 2 was served 1 pkt (packet) graham crackers, 1 pkt lite mayonnaise, 2 pkt mustard, renal garden salad, 1/2 cup of applesauce, renal hamburger, one container of Light & Fit yogurt. CNM stated dry tray meant that kitchen staff should not provide any fluids on the meal tray. CNM stated, "We don't count apple sauce and yogurt as part of the fluid restriction." CNM stated FNS staff were trained to provide dry meal trays for 1,200 ml FR orders, as the 1,200 ml of fluids was "all given by nursing."

During a review of "Dialysis Patient Citizens Education Center (DPC)", dated 2025, the "DPC" indicated, "Why Should I Care About Restricting My Fluids?
Too much fluid gain between treatments can lead to: Cardiac arrest [heart attack],
heart disease, vein damage, blood pressure-related issues, swelling, fluid build-up in the lungs, cramping during treatment. . .1 cup of yogurt = 7 oz. of fluid, 1 cup of applesauce = 8 oz. of fluid."

During an interview on 6/9/25 at 2:25 p.m. with CNM, CNM stated she did not know the fluid content of high-water foods like yogurt and therefore did not guide staff on counting fluids from certain foods toward FR orders. CNM stated, "Our hospital only wants liquids via beverages to be counted in a fluid restriction."

During a concurrent interview and record review on 6/9/25 at 2:26 p.m. with CNM, CNM stated she used the Nutrition Care Manual (NCM) from Academy of Nutrition and Dietetics (AND) as standards of practice. CNM accessed the NCM, the hospital had readily available for staff, and CNM stated standard of practice per NC for FR was to include foods with high water content and foods that melt. CNM stated it was the hospital that did not want to include foods with high water content as a liquid. CNM stated she did not discuss or clarify further with medical staff related to NCM's guidance pertaining to FR, such as fluid-restriction diet order versus a no-free-water, fluid restriction diet order.

During a review of the policy and procedure (P&P) titled, "Fluid Restrictions", with a created date of 6/2/2008 and an approved date of 6/10/24, the P&P indicated, "Approvers: Director of Food & Nutrition Services, Policy: Physician orders for fluid restrictions will be implemented in conjunction with nursing. Procedure: 1. Fluid restrictions will be communicated via the diet order to the Food and Nutrition Services (FNS) Department. 2. The fluid restriction will be part of the diet order. 3. Fluid restrictions less than or equal to 1250 ml per day will be considered a dry tray. All other fluid restrictions will receive one liquid serving (i.e. soup, gelatin, ice cream, water, coffee, soda, juice, etc) of choice not to be more than 240 ml [8 oz.] per meal. 4. Oral nutrition supplements as ordered by the provider counts towards the liquids provided on each tray. 5. Nursing will record fluids & foods consumed into the patient's medical record."

During an interview with CNM on 6/10/25 at 3:55 p.m., CNM stated she reviewed the above P&P and stated soup was included in FR per P&P and it was not just liquid beverages on a tray that should be counted toward FR. CNM was unclear on the hospital's expectations related to FR orders. The hospital had only required the DFNS to approve the P&P without interdepartmental collaboration, review and approval in which concerns, questions, advice or improvement in the development of a P&P may take place to ensure clear, concise guidance related to FR orders in accordance with standard of care.

During a review of the facility's diet manual (DM), dated 2025, the DM contained a a full liquid diet described as "made up of only fluids and foods that turn to liquid at room temperature", to provide an example of foods that may be considered liquids, which included "broths, strained cream soups, cooked refined cereal, farina, cream of rice, strained cereal, fruit and vegetable juices, milk, milkshake, yogurt, custard, and pudding."

During a review of the policy and procedure (P&IP) obtained from "Patient Care Manual" titled, "Vital Signs, Intake & Output, Weights: (Adult)", dated 3/20/23, the P&P indicated, "Approvers: Medical Executive Committee, Patient Care Policy Approval Committee, Patient Care Policy Committee, Policy: All patients'. . .dietary intake & output will be consistently measured and documented as ordered. . .Each staff member is responsible for entering data that they obtain, reviewing entered data for completeness and accuracy. . .Fluid restrictions: 1. Inform and instruct patient/family on fluid restriction procedures including specific amounts of fluid that is allowed. 2. Remove water pitcher from patient room. 3. Carry forward to the next shift any fluids allowed but not consumed. . ."

During a review of the policy and procedure (P&P) titled, "Diet Manual and Approval Acute Care", dated 7/22/24, the P&P indicated, "Policy: The Nutrition Care Manual is the standard guide and reference for nutrition assessment and care. Policy: The Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM) is the standard guide and reference for nutrition care. The NCM is online and available to all healthcare providers at [name of hospital] health."

During a review of Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM), dated 2023, the "NCM" indicated, "Definition: The fluid-restriction diet order limits an individual's daily fluid intake. Most foods are allowed in this diet, but extra planning is required to coordinate appropriate serving sizes of foods and liquids throughout the day. Note: items that are traditionally considered "foods" may be considered liquids in this diet. A no-free-water, fluid restriction diet order limits or eliminates liquids that are mostly composed of water, including plain water, coffee, tea, and tonic. Indication: A fluid restriction diet is indicated in individuals with congestive heart failure [the heart cannot pump enough blood to meet the body's needs, leading to fluid buildup in the lungs and other tissues], hypertension [high blood pressure], fluid retention, pulmonary edema [excess fluid builds up in the lungs, making it difficult to breathe], hyponatremia [low sodium in the blood], and renal failure [kidneys are no longer functioning effectively to remove waste and excess fluid from the body]. Fluid restriction may be ordered in addition to a sodium restriction to help maintain fluid balance. A no-free water restriction diet order is often ordered for hyponatremia to provide a more liberalized approach. . .Counting Liquids and Foods for a Fluid Restriction Diet: A fluid is anything that is liquid or any foods that melt at room temperature. These foods and liquids must be counted as part of daily fluid intake. . .Examples of fluids include the following: Foods with High Water Content/Foods That Melt: Gelatin, Watermelon, Gravy, Ice cream sherbet, sorbet, Popsicles, Yogurt, Pudding, Soups."

Based on observation, interview, and record review, the facility failed to ensure the facility's diet manual (DM) was developed and implemented in accordance with current national standards for routinely ordered therapeutic dysphagia (difficulty swallowing) diets, and was not consistently used as guidance for ordering and preparing patient diets when the DM guided physician's to order obsolete (out-of-date) dysphagia diets such as "chopped" and "ground" from a no longer recognized National Dysphagia Diet (NDD) system. In addition, Food and Nutrition Services (FNS) department had not had the skillset to prepare rice and scrambled eggs in a safe manner and/or in accordance with current standard of practice IDDSI (International Dysphagia Diet Standardization Initiative) Level 6 Soft & Bite-Sized (SB6) standardized guidance (in which the facility was using an obsolete "chopped" diet as their version of SB6 diet) for one of one sampled patients (Patient 5) that had the potential to affect all patient's prescribed a chopped diet since pureed rice and pureed scrambled eggs was on the chopped diet weekly cycle menu. During a review of the facility's "Patient List Chopped Diet (PLCD)", dated 6/10/25, the "PLCD" indicated there were 8 additional patients prescribed a "chopped" diet located in their electronic health record (EHR). (Patient's 3, 6, 7, 8, 9, 10, 11, 12).
(Cross Refer A-0618, A-0619)

Facility failure to ensure full implementation of IDDSI diets, after the facility had indicated they had already fully transitioned to IDDSI at the end of year of 2021 with no further action plans for the implementation of IDDSI diets and/or interdisciplinary (IDT) staff education, resulted in the facility co-mingling obsolete therapeutic diet orders that was no longer nationally recognized with aspects of IDDSI diet implementation that had the potential to lead to confusion amongst staff, patients and family/caretakers and errors in diet texture for patients with dysphagia. Such errors have previously been associated with adverse events including choking.

Findings:

During a review of the policy and procedure (P&P) titled, "Diet Manual and Approval Acute Care", dated 7/22/24, the P&P indicated, "Policy: To provide a reference for nutrition care, which will be used as a guideline for diet related information. The facility specific diet manual outlines all regular and therapeutic diets available for patients in the facility. The Nutrition Care Manual is the standard guide and reference for nutrition assessment and care. Policy: The facility specific diet manual is updated at least annually and reflects the current meals and therapeutic diet options available for providers to order for their patients. The Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM) is the standard guide and reference for nutrition care. The NCM is online and available to all healthcare providers at [name of hospital] health. Procedure: 1. The facility specific diet manual is reviewed, updated and approved by the Food and Nutrition Services (FNS) Director, Clinical Nutrition Manager and a Medical Staff Representative. . .2. The NCM is kept current and updated at least annually by AND. (The NCM includes research-and evidence-based nutrition care information for more than 100 diseases, conditions, and topics.), 3. Both the facility specific diet manual and the NCM are located on [name of hospital] . . .and is accessible from all computers in the District."

During a review of the facility specific diet manual titled, "[name of hospital] Health Diet Manual (DM)", dated 2025, the "DM" indicated, "Dysphagia Diets: The International Dysphagia Diet Standardization Initiative (IDDSI) has become the professional standard for providing dysphagia diets. The goal is to ensure consistent and safe textures for patients with dysphagia. The names of the diet orders in [name of EHR software) have not changed but the interpretation of the diets are as follows: Diet Order: Chopped; interpretation-IDDSI Level 6 Soft & Bite Sized, Ground; IDDSI Level 5 Minced & Moist, Puree; IDDSI Level 4 Pureed, Blenderized; IDDSI Level 3 Liquidized. IDDSI Level 6- Soft & Bite Sized Indication: This diet is prescribed when patients are unable to safely bite off pieces of food but are able to chew the food into smaller pieces that can be safely swallowed. . .Food pieces should be no larger than 1.5 cm [centimeter] x [by] 1.5 cm (or the width of a dinner fork). Foods should be soft, tender and moist, for easier chewing and swallowing. Foods where sauce separates from the food should be strained or blended to ensure one consistency. Moisten foods with small amounts of gravy, sauce, juice or cooking liquids-but only if it can be absorbed into the food and does not separate. Food Groups. . .Protein - foods allowed: Cooked and soft proteins that are not on the restricted list, Foods Restricted: Poultry or fish with skin and/or bones, Natural casing on sausages, Breads and starches - foods allowed: Soft foods not on the restricted list, Foods Restricted: Crackers, biscuits, muffins, pancakes, waffles, bread dressing, sticky rice or rice that separates into individual grains. . ."

During a concurrent observation and document review on 6/9/25 at 11:11 a.m. in the kitchen during lunch trayline (where prepared meals are assembled onto trays ), Patient 5's lunch meal tray card indicated, "Diet: Chopped; Clerk Check [extra check process for meal tray accuracy]", dated 6/9/25. Patient 5's lunch meal tray was observed to have chopped chicken stirfry, pureed rice that was observed with liquid pooled on top with liquid separation coming out from the side of the thin appearing pureed rice that spread out on the plate, and a cup of gravy that had liquid separation.

During an interview on 6/9/25 at 1:59 p.m. with CNM, CNM stated the kitchen staff always served pureed rice and pureed scrambled eggs for all "Chopped" (hospital's version of SB6 diet) and "Ground" diets (hospital's version of Level 5 Minced & Moist [MM5] diet). CNM stated there should not have been any liquid separation from the pureed rice or gravy served for the "chopped" diet, as that was not allowed per IDDSI SB6 diet standardization. CNM stated the hospital served pureed rice and pureed scrambled eggs for all "chopped" and "ground" diets across the board and was not dependent on patient-specific dysphagia assessment by an ST (Speech Therapist). CNM stated a ST that used to work at the hospital had told the FNS department to serve those food items in a pureed texture for the chopped and ground diet for patient safety. CNM was unable to provide documentation of that communication and/or the name of the previously employed ST or anyone else whom approved that to be implemented hospital wide without being based on an individualized ST assessment to demonstrate the required need for patient-specific safety.

During a review of IDDSI.org, dated 2025, IDDSI indicated, "The risks associated with swallowing a mixed consistency item [such as when liquid separates out from a solid] are as follows:The liquid component of the item may separate and spill into the pharynx (throat) during oral preparation of the bolus (a mass of chewed food). This may represent an increased aspiration risk (when food or liquid enters the lungs instead of going down the esophagus/throat that could lead to health problems) in people with dysphagia. Solid particles may be washed into the pharynx with the liquid component, before they have been adequately chewed. If these particles enter the airway, there is an increased risk of choking and airway obstruction."

During a review of NCM under title, "IDDSI Level 6 Soft and Bite-Sized Nutrition Therapy (SB6 diet)", dated 2022, the NCM for SB6 diet indicated, "Foods Recommended: Couscous, quinoa, or rice held together with smooth, thick sauce that keeps rice from separating into individual grains, Foods Not Recommended: Grainy, sticky, or glutinous rice. . .Level 6 Soft & Bite Sized Sample 1-Day Menu: Breakfast: 1 scrambled egg cut into 1.5 cm x 1.5 cm pieces."

During a review of IDDSI.org under "Frequently Asked Questions", dated 2025, IDDSI indicated, "The average tracheal (a tube in the neck and chest that carries air to and from the lungs) size for adult males is 22 mm (millimeters) and for adult females is 17 mm (Brodsky et al., 1996). Particle sizes of 15 mm (i.e. 1.5cm) size are therefore more likely to pass through the trachea, than block it."

During a concurrent interview and record review on 6/9/25 at 2:05 p.m. with CNM, Patient 5's "Order Desc [OD: description]", dated 2/11/25, was reviewed. The "OD" indicated, "Chopped Diet." CNM stated chopped diet was not an IDDSI diet but "it's our house version for IDDSI SB6 diet (Level 6 Soft & Bite Sized)." CNM stated the physician's ordered "chopped" and "ground" diet orders in a patient's EHR from a pop down diet selection list. CNM stated IDDSI diets were not available in the EHR's pop down diet list for physicians to order for their patients.

During an interview on 6/10/25 at 3:20 p.m. with ST, ST stated she was aware the kitchen provided pureed rice and pureed scrambled eggs for the chopped diet orders which was in place when she began working at the hospital 3 1/2 (three and a half) years ago. ST stated she did find that practice to be unusual and did question it but never received an answer that made sense and did not pursue it further.

During a review of the facility's planned "Chopped" menu that repeated every seven days, dated 6/9/25, the non-select chopped menu indicated pureed scrambled eggs were provided 7 out of 7 days, and pureed rice was provided for six meals during the weekly menu cycle.

During a review of the facility's DM, dated 2025, the DM for chopped and/or Soft & Bite Sized (SB6) diet provided no indication that pureed scrambled eggs or pureed rice was approved to be provided on an IDDSI SB6 diet.

During a concurrent interview and record review on 6/10/25 at 3:30 p.m. with ST, Patient 5's "Speech Therapy Forms (STF)", dated 2/3/25 was reviewed. The "STF" indicated, "Recommendations: 1. chopped diet with thin liquids, 2. Strategies: 1:1 feeding assistance, upright with PO intake, single sips of liquid, slow rate, 3. oral care 3x daily, 4. ST for dysphagia management" signed by ST 2. ST was asked if she was aware that IDDSI was the only recognized dysphagia diets, and that "chopped" and "ground" diets was from an obsolete National Dysphagia Diet (NDD), and ST stated, yes. ST stated the ST's at the hospital performed dysphagia tests, treatment and recommended dysphagia diets to physician's for patients. ST stated ST's provided recommendations on diet textures such as "chopped" and "ground" although she was aware it was an outdated term, but that was what the hospital used. ST was not able to explain why the hospital used out of date dysphagia diet terminology that was no longer nationally recognized. Further, ST stated she had not received training on IDDSI diets.

During a review of "Patient List Chopped Diet (PLCD)", dated 6/10/25, the "PLCD" indicated there were 8 additional patients prescribed a "chopped" diet (Patient's 6, 7, 8, 9, 10, 11, 12, 13). Of those chopped diet orders, five specified thin liquids, and three had no liquid consistency specified.

During a review of the facility's DM, dated 2025, the DM indicated, "Due to the pathophysiology of dysphagia, the IDDSI framework requires that the liquid consistency be clarified by the physician and/or speech therapy prior to sending liquids to drink to the patient. Assumption that the patient can tolerate thin liquid cannot be made. Therefore, if the liquid consistency is not included with the diet order, the FNS department will not provide fluids to drink. It is highly encouraged prescribing physician to include liquid consistency in the diet order for safety and patient satisfaction with meals provided."

During an interview on 6/10/25 at 3:48 p.m. with CNM, CNM stated she had trained FNS staff on IDDSI diets and provided training to medical staff during a meeting a while back. CNM stated she did not know if STs or nursing received IDDSI training.

During review of the NCM, dated 2022, the NCM indicated, "Treatment of dysphagia encompasses a multidisciplinary approach. Physicians and speech-language pathologists (SLPs) evaluate individuals with dysphagia through various procedures. The SLP may prescribe a texture-modified diet for foods and/or fluids and muscle-strengthening exercises and postural [sitting positions] maneuvers to increase swallow safety. The RDN supports the individual with dysphagia by encouraging adherence to texture-modified diet recommendations and recommending acceptable foods and fluids that meet the prescribed diet and nutrient needs. . .Often the entire health care team (including physicians and nurses) is involved in monitoring patients for difficulties related to chew/swallow; in reporting concerns per facility policy; monitoring diet texture effectiveness, adherence, and understanding; and evaluating needs related to patient education. . .The National Dysphagia Diet (NDD) and associated resources will no longer be included in the NCM after October 2021."

During review of United States IDDSI Reference Group (USIRG), dated November 2021, USIRG indicated, "IDDSI has the full support of the Academy of Nutrition & Dietetics (AND) and the American Speech-Language & Hearing Association (ASHA) since May 2019. October 2021: IDDSI is now the only professionally recognized dysphagia diet standard in the Nutrition Care Manual of the AND for the United States."

During a review of IDDSI.Org titled "Guidelines For Use" (GFU), dated 2024, "GFU" indicated, "Supplementary Notice: Do not alter the elements of the IDDSI framework. Alterations may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death."

During a review of IDDSI's document titled "Standards of Practice Regulatory Information for Long Term Care Facilities, Hospitals, Critical Access Hospitals, Home Health Agencies and Hospice", dated July 2021, indicated, "The National Dysphagia Diet (NDD) is now outdated and International Dysphagia Diet Standardization Initiative (IDDSI) will be the only professionally recognized texture modified diet framework as of October 2021. . .It is the only professionally- supported and evidence-based standard of practice."