Thought we might be done reviewing regulations on the CMSCG Blog? Nope, we’ve still got plenty to review! Our first 2024 “Ftag of the Week” on the CMSCG Blog is part of the Food & Nutrition regulatory group, F805 Food in Form to Meet Individual Needs. This regulation is light on content requirements, but if there’s a systems failure in this area it can certainly result in an Immediate Jeopardy citation. Since there’s always such an emphasis on the risk of an IJ related to common high-risk areas such as elopement, abuse or med errors, it’s important to remember there are many areas where there can be a negative outcome – including during meal service.
F805 – What’s Required
According to Appendix PP of the State Operations Manual (SOM), facilities are required to provide, and ensure each resident receives, food that is prepared in a form designed to meet each individual’s needs.
That’s it. No big deal, right? Unfortunately, F805 is cited throughout the country often at a pattern or widespread level, since incorrect modified texture diets can impact more than one resident. Let’s review some actual survey citations and discuss key areas to think about to avoid a high-level citation in your facility.
Recertification Survey Citation – F805 S/S: J (Immediate Jeopardy)
Citations like this one are the poster child for why a facility needs to ensure food is prepared to meet each resident’s needs. A resident with dysphagia who had orders for ground meat was served a whole hamburger patty and choked, requiring the Heimlich Maneuver. Staff stated that the resident did not show any signs of a negative outcome after this event, but once surveyors reviewed the resident record, they found that a few days after she choked, the resident was transferred to the ER and ultimately admitted to the ICU with a diagnosis of Pneumonia.
While the survey team was onsite, they observed another resident’s tray contents which did not match his meal ticket. The resident had orders for a dysphagia mechanically altered diet. He did not receive items in the correct consistency, including whole pieces of bread with his dinner.
The next day during tray line observation, the employee who was responsible for checking the accuracy of the tray was interviewed. She stated that she was from a different facility and her assignment was to check tray accuracy and supply drinks. When asked about how she verified tray accuracy, the employee stated that she was aware one of the colored tickets was for allergies, but she was not sure what the other colored ticket was for because her facility did not use tickets that were colored. She was unaware of the altered fluid consistency ticket color but stated that she always reads the ticket to check the correct fluid consistency before providing a drink.
The surveyor asked her to review the tray and ticket for the resident who had received whole bread the prior day. She was aware he was on a mechanically altered diet but could not answer if bread was allowed to be included on this diet. The surveyor asked two other dietary aides who were on the tray line and confirmed neither knew if bread was allowed for residents with orders for dysphagia mechanically altered diets.
While the second resident did not experience a choking event like the first resident, it is understandable that harm could have occurred when a resident was provided with the wrong diet texture. Unfortunately, since staff were not able to explain to the surveyor what food items were acceptable on a dysphagia mechanically altered diet, this could have resulted in other tray accuracy issues. Only the cook and the SLP – neither of whom were responsible for checking tray accuracy – were able to confirm which foods were acceptable for this form of therapeutic diet.
There’s obviously a difference between tray accuracy related to a resident getting a drink that isn’t to their preference and a prescribed therapeutic diet to address a clinical condition or disease. It’s important to ensure that all staff who are responsible for meal service have sufficient knowledge of food and fluid consistencies as well as items allowable on each diet served by the facility to prevent negative outcomes. As you’ll see in the next example, depending on the surveyor, these types of issues can result in varying severity (isolated vs. pattern).
Recertification Survey Citation – F805 S/S: K (Immediate Jeopardy)
During an observation of lunch service, staff plated a general diet for two residents. Those two residents were supposed to receive mechanical soft diets. Once the surveyor observed this, he checked and found that there were six additional residents who were not listed on the diet type report but required a mechanical soft diet, and four of those residents did not have a doctor’s order for a mechanical soft diet. This resulted in immediate jeopardy.
While this citation is about residents not receiving their ordered diet type during meal observation, this surveyor dug deeper and found that several residents who should have had orders for mechanical soft diet did not have orders for the same. Without the appropriate orders, the meal tickets would never be “accurate” to meet the residents’ needs, but instead of it being a lack of staff knowledge or an inaccurate diet roster, this was due to a lack of physician’s orders. This had the potential for issues to occur for multiple residents, so that likely contributed to the higher scope and severity.
Recertification Survey Citation – F805 S/S: K (Immediate Jeopardy)
After dietary staff did not arrive at the facility for work, staff took matters into their own hands to ensure residents received their meals. Three CNAs and a central supply clerk prepared and served breakfast, lunch and dinner to residents. Was the IJ a reward from the survey team for taking initiative to ensure the residents were fed? Not quite. Unfortunately, the staff failure to provide ordered puree diets for multiple residents. The staff replaced the pureed diets by chopping food into small pieces and not smooth consistencies.
A surveyor interviewed one resident with orders for a pureed diet, and she stated that she was unable to eat, and no items of the correct consistency were provided to her for all meals due to dietary staff being unavailable.
On interview, the Administrator told the surveyor that he lived out of state but had come to ensure meals were delivered to the residents. He had no previous dietary experience and did not offer additional direction on meal service other than to tell staff to follow the meal tickets. The Regional Dietary Consultant was interviewed and told the surveyor that she did not come to the facility to assist with meal service or remain available by phone to offer assistance or instructions on how to prepare meals. The clerk who was assisting with meals told the surveyor that he had some kitchen experience, but no one preparing meals knew how to use the kitchen equipment, so they tried to make pureed items as small as possible and mash foods with a potato masher.
While it’s unclear what was going on that the dietary staff, including the Dietary Manager, didn’t show up for work and couldn’t be reached when called, it’s still understandable that this facility was put in Immediate Jeopardy. What’s worse is they didn’t end up with just one IJ-level citation. Not surprisingly, the facility was given an IJ under F802 Sufficient Dietary Support Personnel (S/S: K) after it did not ensure that dietary staff arrived to work as scheduled. The facility was also cited at F835 Administration (S/S: K) due to the Administration’s failure to provide effective leadership and oversight to ensure effective systems were in place to have trained dietary staff available to prepare meals for the residents.
So, as you can see, there’s limited regulatory language and limited guidance, but identified deficient practices under this Ftag can create a large headache – or worse, a negative outcome for one or more of your residents.
