Is pureeing food for a dysphagia diet a task that must be done by someone qualified in skilled nursing?

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Question for RNs and LPNs. I was told today by representatives of a private duty home care company that pureeing food for a client is considered skilled nursing and can only done by someone qualified as such. Any input on this? I asked a relative about this but was confused at the time and can't recall her answer!

Answers 1 to 10 of 38
I am a RN and haven’t ever heard this. I will have to research the Nurse Practice Act. What state are you in?
My curiosity is piqued.
Did you ask the agency if this is so and why?
I have never heard of this or had any mandatory training on how to puree food. I have never seen it as a requirement or listed in a skill set.  
Shane, I'm in Michigan. This is the first time I've heard of this as well. I didn't ask the agency b/c I was actually in somewhat of a state of shock, thinking of all the private duty agency reps with whom I had spoken who all said their staff could puree foods for clients.

Duck, this is the first I've ever heard of it as well.

The explanation was, more or less, that since it was related to dysphagia, it was an issue for a nurse to handle.

I wasn't asking for speech therapy, or swallowing exercises, just to puree foods. They explained their caregivers would feed clients (we don't need that) but could not puree the foods.

The more I thought about it, it really seemed odd to me. If it's true, then it would seem that kitchen staff in rehab or any other facility couldn't puree the food either, and I know that the rehab facility where Dad stayed didn't have nurses pureeing the food.

I'm still at a loss as to what's behind the claim.

Thanks for your input; I wish I'd had the presence of mind to ask the basis for their conclusion. If I speak with them again, I will ask.
I'm in Indiana, and my dad is in MC here. His facility cannot provide a dysphagia meal plan, so if he needs that, he'll have to move. Not sure if that's bc of the state certification for facility type or their choice. (This is not a SNF, but AL with a MC unit.)
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I've been a RN for over 20 years and have never heard of this either. I will check the AZ Board of Nursing to see if there is any truth to it. I know in the hospital, we have trained family on how to do complex dressing changes, Run long term IV antibiotics, and other such IV fluids. How to connect and flush feeding tubes....Never ever heard anything about pureed food. Really, if that's the case would people need special licenses to feed babies?
Laws may vary by state but mom's memory care - considered assisted living by state - has the kitchen staff purée the food

I've seen regular caregivers take a jar of thickener and pour unmeasured into a glass of juice

I would think if meal prep is part of the service then putting it into a blender shouldn't be an issue - if so can you purée ahead of time so they are merely heating up in the microwave ?
I should think it's not the puréeing per se as the supervising of a person with impaired swallowing reflex that puts this into the "skilled" category.

Sounds to me like one of those unintended consequences of well-intentioned guidelines. In a similar way, only nurses or SLTs who had done the specific training were allowed to assess swallowing reflexes in stroke patients in our local hospital. The upshot - apart from my turning into a gremlin and biting metaphorical chunks off people - was that my mother lay on a a specialist stroke ward for seven hours without water because none of the many nurses and doctors present were "qualified" to assess her swallow reflex. Of course they were bloody qualified! - just not on the right list.

What about if you purée the food yourself, put it in sealed containers in the fridge, and ask the HCAs to warm it through in the microwave?
I imagine this is more of a liability issue than a health one since nurses have no more training in dietary modifications than CNAs do, but if a client aspirates or chokes on improperly prepared foods or beverages the company can claim due diligence.
Never heard of this either. There has to be more to the reasoning.
A Speech therapist and interventional Radiologist have to do the testing for dysphagia. Maybe this testing has not been done and the agency does not want to run the risk of the patient choking. Actually come to think of it the reason is right there. Only a skilled professional is able to handle the treatment for a dysphagia patient who aspirates. So it is not actually the use of the blender that is the problem
Responding to those who posted after I addressed Shane's and DDDuck's responses...

Thanks to each of you for taking the time to respond. I really appreciate it!

Talkey, I'm sorry to learn that your father's memory care facility doesn't offer dysphagia food, and hope for his and your sake that he doesn't have to address that issue. I think perhaps a facility needs to have a speech therapist or speech pathologist on staff in order to offer dysphagia meals, and if the facility chooses not to, or can't for some reason, that option probably wouldn't be available.


Blue8385, good question on how baby feeding could be done if parents would have to hire someone to puree the food! I recall that I was taught how to manage PEG tube feeding by rehab staff, and your post reminded me that nurses do sometimes train family how to do semi-nursing tasks.

I'm going to see what I can find out from the Michigan Nursing Board, or other Michigan nursing or dysphagia guidelines. I hadn't thought of checking state organizations. Shane also mentioned the Nurse Practice Act. Maybe that would offer some insight as well.


Ms. Madge, as I understand the conversation of yesterday, the staff can prepare (i.e., microwave) meals and serve them, just not puree them. But serving wasn't what I requested as Dad can do that himself. He just can't puree the foods.

Ms. Madge and CM, I wanted someone to puree because the extra trips to Dad's house as well as the time to puree the foods, especially the MOW foods which have smaller portions that are literally too small for the food processor, are more tedious. At first it took about 1/2 hour just to fuss around with all the little portions.  And that's just for one meal.  I try to puree enough meals for at least 3 - 4 or more days, and that takes 2 - 3 hours, depending on how many little cups of food there are in the MOW trays, and how much the meat portions have to be chopped up before pureeing. 

And the working conditions are such that there's no way I can do it w/o aggravating a back condition that developed last year. So every time I puree, I go home with a backache.

As to my handling the pureeing, that's the situation now, but it's requiring additional trips, lots of extra time, and other caregiving tasks are being subordinated or not getting done. Dad's needed a higher level of care since the last hospitalization, and I'm feeling overwhelmed and unable to keep up with it, in addition to getting annoying regular backaches.

So it was my intention to hire someone to handle this so I could get back to the other tasks, including the legal work (which I started on months ago but haven't been able to finish).  I'm actually years behind on some of the work that needs to be done.

I also asked Dad's occupational therapist about Dad doing some of the pureeing; she made some observations and gave me a large "thumbs down". She felt it would be too dangerous for him, b/c of the standing while pureeing, walking back and forth to the sink to clean the utensils, danger of contact with the blade, and more. I was in agreement with her. I cut myself pretty badly once when I wasn't careful handling the blade.

In addition, his unfortunate encounter with the blade of a radial arm saw 2 decades ago left his right hand not completely functional. He has a hard time just removing lids from the containers, so I leave them partially open and hope that he doesn't spill them. Those are complicating factors.


CM, I'm sorry to read about the ordeal your mother experienced b/c of lack of someone to assess your mother's swallowing reflexes. Sometimes regulations meant to improve care actually impede it.  My mother once waited  for several hours on one of those cold slab tables until the one operating room became available to fix her broken leg.    Our tempers provided some warmth for us as we became more and more angry about the situation, but our wrath didn't help her in her discomfort.

In my experience, a speech pathologist is always brought in to do the assessment, but the nurses and other staff are expected to implement the restrictions.   And the kitchen staff was pretty strict about implementing - the restricted list of foods was always provided to them. 


CWillie, interesting comment about due diligence and legal caution. That might be an issue if the food isn't pureed to Dysphagia, level 1 standards, and that's not always possible, especially with fibrous vegetables.

This agency might be especially cautious anyway; it does seem to have higher standards than many of the agencies I've contacted, including the owner of one who claimed he could train a private duty caregiver in 4 hours. Hmmm....I don't think I'd want one of his people on my team.


Veronica, the last videoscopic swallow was in May; another would be required before I can get palliative care with speech therapy included. I want that b/c I want the exercises to be part of the therapy; the Shaker exercises are what restored his swallowing function back in 2004.

"Only a skilled professional is able to handle the treatment for a dysphagia patient who aspirates."

So then there would be a distinction between pureeing food, which might be considered treatment, but microwaving wouldn't be, so the caregiver could do that?

And I thought law was so particular and precise in analysis of issues!


Thanks to everyone for taking the time to respond. After I get another pending crisis controlled, I'm going to probe the issue in more depth with the company rep and find out what the real reason is.

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