**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure food was prepared in a form designed to meet individual needs for 1 Resident (R) (R1) of 7 residents on mechanically altered diets. R1 had a mechanically altered diet. R1's diet was not followed on 11/7/23, which resulted in a choking episode that required intervention by nursing staff and emergency medical services (EMS) to clear R1's airway. R1 passed away on 11/7/23 as a result of the choking episode. Failure to ensure foods were served to residents in the appropriate texture created a finding of Immediate Jeopardy (IJ), which began on 11/7/23. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 11/9/23 at 3:45 PM. The immediate jeopardy was removed on 11/9/23; however, the deficient practice continues at a severity/scope level of D as the facility continues to implement its removal plan. Findings include: According to data from the National Safety Council, choking is the 4th most common cause of death. https://injuryfacts.nsc.org/all-injuries/deaths-by-demographics/deaths-by-age/data-details/ As of October 2021, the Academy of Nutrition and Dietetics announced International Dysphagia Diet Standardization Initiative (IDDSI) is the only professionally recognized standard of care for texture modified diets in the Nutrition Care Manual of the Academy of Nutrition & Dietetics for the United States. The facility's Diet and Diet Orders policy, with a revision date of 5/14/21, indicated: All diets will be prescribed by the Attending Physician. The Dietitian will review diets for accuracy and therapeutic goals and recommend changes to the Physician as deemed appropriate .When necessary, the Attending Physician will order therapeutic or mechanically altered diets to address certain diseases .8. The regular menu will be modified and reviewed by the Dietitian and for both therapeutic and consistency modifications, with input from the Food Service Manager or Dietary Manager. Spreadsheets will be available and used by the dietary staff in the service of all meals to ensure food provided is consistent with diet order. 9. The Center will utilize a tray identification system to ensure diet accuracy in the service of the meals .11. Residents on therapeutic or mechanically altered diets will not receive foods or fluids outside the diet order unless approved by the Attending Physician in conjunction with the Dietitian, nursing and/or therapy .Responsibilities: Dietitian - Monitor compliance with policy by ensuring accuracy of diets and communicating changes or recommendations. Ensures that care plan is updated with diet changes. Food Service Director/Dietary Manager - Ensures that food provided is consistent with diet order and that tray card accurately reflects resident/patient diet order and food preferences. Therapy Department - Screens, evaluates and treats residents/patients as applicable to provide least restrictive diet consistency. Provides written documentation of changes to diet or liquid consistency. Nursing Department - Enters diet orders in EMR (electronic medical record) per Physician's order and in compliance with approved diet type and texture. In cooperation with the other departments, ensures appropriate diet and liquids are provided and reports any discrepancies .Instructions: All diet orders must be consistent with diets offered .Diets offered will be as follows: .Diet texture: .Level 7 Easy to Chew . The facility's undated IDDSI education indicated: The International Dysphagia Diet Standardisation Initiative (IDDSI) is a global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures .7. Easy To Chew Description/Characteristics: Normal, everyday foods of soft/tender textures .Does not include: hard, tough, chewy, fibrous, stringy, crunchy, or crumbly foods .This level could present a choking risk for people with clinically identified increased risk of choking, because food pieces can be of any size. Restricting food piece sizes aims to minimize choking risk .(the next statement was added by the facility and not part of the original IDDSI verbiage) MOST SIMILAR TO DIET CALLED MECHANICAL SOFT - our policy calls for this level to have chopped meats .(original IDDSI verbiage resumes here) Food Specific Examples: Meat - Cooked until tender .(the next statement was added by the facility and not part of the original IDDSI verbiage) Per our policy, meat will be chopped unless tender enough to be flaked (fish) .(original IDDSI verbiage resumes here) Bread, sandwiches and toast that can be cut or broken apart into smaller pieces with the side of a fork or spoon can be provided at clinician discretion . On 11/9/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease, cognitive communication deficit, and dysphagia (difficulty swallowing). R1's Minimum Data Set (MDS) assessment, dated 9/11/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was not cognitively impaired. R1's Power of Attorney for Healthcare (POAHC) document, dated 11/13/14 and activated on 3/12/19, indicated R1's POAHC was responsible for R1's healthcare decisions. On 11/9/23, Surveyor reviewed R1's physician diet order which stated, Heart Healthy (Cardiac) diet, Level 7 Easy to chew texture, Level 0 Thin (Regular) consistency. On 11/9/23, Surveyor reviewed R1's care plan which stated, I have potential for altered nutritional/hydration status . with interventions to include DIET TEXTURE - Level 7 - Easy to chew. On 11/9/23, Surveyor reviewed a nursing progress note which indicated: 11/7/2023 .Writer alerted to choking episode in dining room. Heimlich maneuver initiated by (Registered Nurse (RN)-E) was unsuccessful. (R1) assisted to floor by (Director of Nursing (DON)-B), therapy and CNA (Certified Nursing Assistant). Crash cart obtained and suction started. (R1) was side lying while attempts to clear the obstruction continued. EMS were notified. (RN-G) attempted side lying Heimlich without success. (R1) noted to have weak pulse - not breathing, cyanotic. EMS arrived on scene and assumed care. At time of EMS arrival, (R1) was pulseless and non-breathing. Code status confirmed DNR (Do Not Resuscitate). EMS was able to clear obstruction with forceps and suction. Leads attached with no viable heart rhythm noted. Police present at time . On 11/9/23, Surveyor reviewed R1's physician code status order of DNR/No Code and R1's Wisconsin form titled Emergency Care, signed and dated by R1's POAHC and physician on 6/30/23, that indicated Emergency providers as appropriate will provide .Clear airway and Emergency providers will not .perform chest compressions . On 11/9/23, Surveyor reviewed the facility's report document, with date occurred 11/7/23, that indicated: (R1) unexpectedly passed away as a result of a choking incident in the dining room. (R1) was observed choking at approximately 12:54 PM and staff responded immediately and appropriately to the incident .Facility has suspended pending investigation staff that were involved in the event from dietary service to table service. Staff education initiated immediately on diet consistencies. Audits initiated immediately for cook to sign off on any resident on an altered diet consistency. On 11/9/23, Surveyor reviewed the facility's investigation which included the following staff interviews: Dietary Aide (DA)-C's handwritten statement, dated 11/7/23, indicated: I was rinsing dishes at the window by the dishwasher. I glanced up when I was putting a dish on a rack and saw (R1) was choking on (R1's) lunch. I immediately stopped what I was doing and ran into the dining room, which only took a couple seconds. I told the CNAs in the dining room (R1) was choking and they immediately called out for a nurse. CNA-D's handwritten statement dated, 11/7/23, indicated: I was sitting in the dining room feeding another resident when I heard a kitchen aide say 'I think (R1's) choking'. I looked around, noticing it was (R1). I went over to (R1) and confirmed (R1) was choking. I began to pat (R1's) back, when (R1) spit milk out of (R1's) mouth. I then screamed for help stating 'I need a nurse for help'. The nurse (RN-G) came running in for help. (RN-G) then stated to me to grab the crash cart and I did so. I continued to assist the nurse, until the hot dog was out of (R1's) throat. RN-E's handwritten statement, dated 11/7/23, indicated: Writer alerted to choking episode in dining room. Writer initiated Heimlich maneuver unsuccessfully. (R1) was assisted to floor by (DON-B), CNA and therapist. Crash cart obtained. Suction started. EMS activated. Continued attempts to clear obstruction. (RN-G) attempted side lying Heimlich without success. Weak pulse noted. Attempts to suction and clear continued. EMS arrived - noted no pulse, not breathing. EMS confirmed code status and continued to attempt to clear obstruction. EMS was successful in removing the obstruction with forceps and suction. No viable heart rhythm noted on leads. Police present. Medication Technician (MT)-F's handwritten statement, dated 11/7/23, indicated: (CNA-D), (DON-B), (RN-E) and I lifted (R1) out of (R1's) chair and put (R1) on the floor. (RN-E) used suction on (R1). We rolled (R1) to (R1's) side, patted (R1) on (R1's) back, suctioned and encouraged (R1) until EMT (emergency medical technicians) arrived. RN-G's handwritten statement, dated 11/7/23, indicated: When writer entered dining room, (R1) was on (R1's) left side with (DON-B) holding (R1's) head and nurse manager suctioning. (R1's) lips were purple, agonal breathing (short, labored, gasping breaths), sending faint pulse. Writer attempted abdominal thrusts for 15 seconds until ambulance arrived. We turned (R1) onto (R1's) back, opened the airway and attempted to remove sausage from blocking airway. Once small piece removed, (R1) went pulseless and eyes became fixed. Second larger piece was removed and leads showed (R1) was in PEA (pulseless electrical activity) and is a DNR. On 11/9/23 at 11:18 AM, Surveyor interviewed NHA-A who indicated NHA-A learned from interviews with staff that R1 was given the wrong food. NHA-A indicated the report from the staff interviews was not yet written and NHA-A had handwritten notes only. NHA-A indicated after the incident on 11/7/23, NHA-A spoke to Dietary Manager (DM)-H who told NHA-A that DM-H let [NAME] (CK)-I know R1 requested a hot dog on a bun and DM-H told CK-I to cut it up. NHA-A indicated CK-I assumed DA-C heard the directive from DM-H. NHA-A indicated DA-C told NHA-A that DA-C did not hear the directive from DM-H. NHA-A indicated the cooks were to have altered diets ready to serve. On 11/9/23, Surveyor reviewed undated handwritten notes by NHA-A who stated the notes were written on 11/7/23 during event and with start of investigation. The notes indicated: .(DM-H) told (CK-I) to cut the hot dog. (CK-I) did not cut hot dog. Hot dogs left whole for person serving. Assumed server heard. (DA-C) said (DA-C) did not hear that . On 11/9/23 at 11:50 PM, Surveyor interviewed Speech Language Pathologist (SLP)-J who verified SLP-J was involved in the assessment of R1's dietary needs. SLP-J stated, We tried pureed, but (R1) didn't like it. (R1) did fine on easy to chew (diet). When asked how small a cut up hot dog should be on a Level 7 Easy to Chew diet, SLP-J stated, Have to be able to cut with tongs of a fork on the side. Has to soften with a fork. Really not a size thing. Could serve someone a whole piece of salmon. Salmon is soft. Ground up hot dog would be easy to chew. Cut up hot dog would not be easy to chew .That would be what I'm comfortable with. When it says 'meat to be chopped', I would say into very small pieces. Like two-centimeter pieces probably. Small enough that it would soften with fork. On 11/9/23 at 12:47 PM, Surveyor observed a food item in a zip-lock bag in NHA-A's office. NHA-A verified the item was a piece of Kielbasa sausage which EMS pulled from R1's throat. The piece of Kielbasa was approximately two inches long and a little over one inch wide. The bag also contained a full Kielbasa sausage that was six and a half inches long and a little over one inch wide. NHA-A verified the full Kielbasa sausage was an example of what was served to R1 on 11/7/23. On 11/9/23 at 12:49 PM, Surveyor interviewed NHA-A who indicated the lunch meal on 11/7/23 was French onion pork loin, scalloped potatoes, and green beans. NHA-A indicated alternate meal items always available were soup of the day, sandwich of the day, salad with protein, and hot dog with bun. On 11/9/23 at 1:05 PM, Surveyor interviewed DM-H who indicated a Level 7 Easy to Chew diet required meats to be cut up into smaller pieces. When asked how small, DM-H stated, Level 6 is 1.6 centimeters, but bigger than that for Level 7 .We do chopped (meat) here for Level 7. Level 6 should be ground (meat). When asked about DM-H's instructions to CK-I for R1's lunch meal on 11/7/23, DM-H stated, The cook was not in the kitchen when I first heard (R1) wanted a hot dog for lunch. I left a note telling the cook (R1) wanted a hot dog for lunch. DM-H indicated the note did not instruct CK-I to cut up the hot dog. DM-H stated, So I talked to the cook to tell (CK-I) to cut up the hot dog in case (CK-I) didn't think of it. When asked if R1 was served a hot dog or a Kielbasa sausage, DM-H stated, It was a Kielbasa. (R1) was okay with getting that since we didn't have hot dogs, but it (Kielbasa) should have been cut up. When asked what size DM-H expected CK-I to cut the Kielbasa, DM-H stated, The way I cut it up, and the way I would expect them (cooks) to do it, is down the long way, then those strips cut the long way again so four long strips then cut the strips in one-half inch pieces. (1.2 centimeters equals one-half inch.) On 11/9/23 at 3:15 PM, Surveyor interviewed SLP-J via phone. When asked if SLP-J authorized any adjustments to R1's Level 7 Easy to Chew diet, SLP-J stated, I don't think so .I know I didn't adjust for Kielbasa. When asked if bread was allowed on a Level 7 Easy to Chew diet, SLP-J stated, Anyone can have bread on that diet .anything fork tender. Bread on Level 7 should be fine. A piece of bread. When asked if a bun was appropriate for a Level 7 Easy to Chew diet, SLP-J stated, Bun is fine. I would say that qualifies as easy to chew. Meat only if sliceable on side of fork. When Surveyor asked SLP-J's thoughts on the Kielbasa alternative, SLP-J stated, (R1) was not given correct texture. Not the right item. (R1) maybe could have been given Kielbasa in another form. Cut up into a size that loses its form with a fork. Or ground up. SLP-J indicated adjustments to IDDSI diet levels should be specifically added to a resident's diet order and care plan. SLP-J further stated, I didn't even know we (facility) served Kielbasa. The failure to ensure a resident received food in the correct form led to serious harm which created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy. The facility removed the jeopardy on 11/9/23 when it completed the following: 1. Reviewed all residents' diet orders and tray cards for accuracy. 2. Reviewed the IDDSI Level 7 Easy to Chew Framework with staff and updated the facility's policies and procedures accordingly. 3. Educated staff on the requirements of F805 and serving food in accordance with residents' diet orders. 4. Initiated meal and snack audits.