Dietary Restrictions & Food Safety in Managed Care Settings Expert Article

Various physical and cognitive conditions may put certain individuals at risk while eating or drinking. This article reviews the standard of care for facility-based programs to safely provide food and fluid to at risk individuals.

Food Safety in Managed Care Settings - Expert Witness

Food Safety for Individuals with Physical or Cognitive Impairments

A portion of all people in facility-based programs (childcare, nursing homes, assisted living, group homes, hospital settings, educational settings, etc.) suffer from conditions that make them vulnerable to choking, aspiration, and asphyxiation. These risks are best managed through comprehensive programs that assess the needs of each individual and implement corresponding interventions, an approach that is often referred to as the continuum of care. 

In some settings, the continuum of care is referred to as the Quality Assurance and Performance Improvement (QAPI).


An important part of the forensic investigation is to understand if care providers conducted a proper assessment to determine the specific needs of the individual. The assessment process is helpful for analyzing notice as it represents what the care providers knew or should have known at specific points in time.

Within the continuum of care, HRE (health care, rehabilitation, education) professionals need to consider the intrinsic and extrinsic factors that can affect an individual. Information sources that may be relevant to your case can include, but are not limited to:

  • Individual’s records
  • Staff assessment
  • Family and individual reports and interviews
  • Direct and indirect observation 

To satisfy the standard of care, information available to HRE professionals should inform the subsequent care plans that define functional limitations and set the stage for the implementation of appropriate interventions.

Identification, Evaluation, and Analysis of Risks

Records from the assessment process are helpful for forensic investigators to determine if HRE professionals properly identified potential food safety risks. This includes utilization of intrinsic and extrinsic data about a specific individual, including specific diseases and conditions that can affect the ability to safely consume foods and fluids.

For example, an individual with cognitive disabilities may not have been identified as being unable to eat independently. The person may not be able to determine a safe size or amount of food to consume with each bite, how to safely masticate and swallow, or how to correctly utilize utensils. Additionally, the individual may become easily distracted during eating and drinking.

Environmental distractions such as a television or people occupying the same dining area may cause them to become unfocussed and “forget” to fully chew or swallow food or fluids. All of these factors put the person at risk for malnutrition, choking, and aspiration and therefore may require interventions to assist during meals.

It is important to note that the presentation of impairments is not static. This requires constant reidentification, evaluation and analysis to assess effectiveness. It is the responsibility of the interdisciplinary HRE members to communicate this to their teams.

Implement, Monitor, and Evaluate Interventions

Appropriate interventions are key for vulnerable individuals to ensure safe and sufficient nutritional intake. Within the context of a dispute, forensic investigators commonly seek to determine if interventions were appropriate, properly implemented, and/or monitored for effectiveness.

Interventions should be clearly communicated and carried out by an interdisciplinary team in conjunction with the individualized care plan. Interventions will have an outlined process for implementation, timeframe for utilization, and defined reevaluation points.

The reevaluation of interventions is critical to the cyclical nature of the continuum of care. Once interventions have been developed, implemented, and communicated to the HRE professionals, monitoring, and evaluating their effectiveness should occur.

Forensic investigations will seek to determine if the process of monitoring considered the intrinsic and extrinsic factors, including but not limited to assessing the individual’s function in changing environments, determining if a particular time of day impacts cognition, or whether medication changes have impacted function. 

If monitoring reveals a change in the individual or that interventions were not effective, the standard of care would call for new interventions to ensure safe and sufficient nutritional intake. Changes to these interventions should account for evolving intrinsic and extrinsic factors that are constantly being reassessed for the individual. The process does not stop with changes to the intervention, but rather starts the process all over again. The changes made need to be assessed, evaluated, and analyzed again to determine efficiency. Therefore, the CoC/ diagram is represented as a continuous cogwheel, and its implementation should be utilized as such.


Throughout all HRE settings, supervision plays an important part in food and fluid safety. Appropriate supervision should be provided by individuals who are knowledgeable about the care plan and how to apply the identified interventions. Examples of different issues and interventions that HRE employees need to consider include:

  • Temperature of food and liquid
  • Consistency and particle size
  • Allergies
  • Appropriate utensil, dishware, or drinkware
  • Surrounding environment
  • Visual supervision
  • Physical assistance

Food Safety Cases in Managed Care Programs

Food service cases involving vulnerable individuals may draw on experts from our health care, education, and behavioral health practices. Robson Forensic has in-house experts specializing in program administration, individualized care, and physical and cognitive evaluations. Submit and inquiry or contact the author of this article to discuss your case. 

Submit an inquiry to discuss your case with an expert.

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Joseph Muniak, Doctor of Occupational Therapy & Health Care Administration Expert

Joseph Muniak, MS, OTD, OTR/L, CBIS, HEM

Doctor of Occupational Therapy & Health Care Administration Expert
Dr. Muniak is a board-certified Occupational Therapist (OTR) and hospital administrator with expertise in the continuum of care provided to patients in the acute hospital, inpatient rehabilitation,… read more.


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