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

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.)

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.

Easiest way to find out is call another Home Health company and tell them what you need done. If you get the same answer 3 times, I'd say that's the answer in your state.

GardenArtist, Dad should be on a dysphagia diet now, but he was for 2 months back in 2015 & hated it. After that, he told the speech pathologist that he just wanted to eat what he wants. (He's 10 years into Parkinson's, & he had been thru the swallow tests.) I used Meals on Wheels for his dysphagia diet for that 2 month period. When he was upgraded to mechanical soft, I bought inexpensive Oncor meat trays & meals, bc their meats were the softest. I've been looking on MOW's web-site here to verify that they still offer them, but it's unclear. Bless your heart; I know how hard it was for me until I found out they could help.

jjariz,, I did advise all the other private duty companies that dysphagia was the top issue and that I wanted pureeing to be a top priority. They all indicated they could do it. Great!

However, in the process of speaking with different companies, I found that some of them were less than truthful on other issues. In retrospect, I think they told me what they thought I wanted to hear.

But no one raised the issue of pureeing being a skilled nursing task.

Interesting suggestion though.

Talkey, I fully understand your father's position. Eating and chewing offer such rewards that eliminating the chewing part is a significant change in the pleasure of eating.

We did discuss eating whatever Dad wants, acknowledging the risk for aspiration pneumonia. The last hospitalization and rehab were probably the worst he's experienced, so I think that factored into his decision to adapt to mushy foods.

As an aside, and a little anecdote, he loves ribs. Knowing that he couldn't eat them was what I thought would be a major sacrifice. But MOW offers a riblet dinner. With help from MOW, I contacted the supplier and found that I can get these tasty boneless riblets, about 20 in a case for around $38. They're so soft that they puree very easily.

Dad does get MOW and has gotten them for years. But the dietician advised that they can't do mechanical soft or pureed foods. I'm really interested in the fact that you're able to get that accommodation. I know there are close to 200 families that get MOW in Dad's area, so it might be that time just isn't available. The MOW staff are incredible; they're so helpful, and I have a lot of respect for them.

Thanks to both of you for your suggestions.

GardenArtist, check momsmeals.com --I think they were a bit more expensive, & you have to be able to store something like a week's worth in a freezer, then microwave. Not sure; it's been a couple of years. Interestingly, Dad loves his ribs too, & a couple of weeks ago I took him to an O'Charley's restaurant, bc I thought they cooked theirs tender enough for him. Annnnd ...I was right! But his taste isn't the same, so he doesn't enjoy any food like he used to, and he thinks it's bc everyone is cooking it differently. Not sure what our future holds, bc I had hoped he could stay in this place for the duration, but he's had a number of really hard days with food. Our local grocery chain here makes a peaches and creme oatmeal that he likes, tho, and so I keep a stash at the facility for the staff to make for him when he can't eat whatever they're serving. Is your dad a Parkinson's patient?

We saw a Mom's Meals truck one day and looked them up. They offer pureed meals. We haven't tried them out yet.
http://www.momsmeals.com/independent-at-home/pureed-menu/

$8 per meal plus shipping would get pretty expensive compared to the cost of MOW or home made, and the menu is limited, however I used to purchase similar meals to keep on hand for those times when doing it myself was just too much.

GA, I think I would just buy those Bento divided meal boxes from amazon and prepare meals in bulk batches to freeze. I know that plastic containers are not the best, but at this point in his life microwaving plastic containers is the least of your worries. Even if you treated them as single use it would still be more economical than buying prepared meals, plus you would be able to provide a more personalized and varied diet.

It might be that some elected official in your state has gotten a law passed about it. Like the "Right to Fall" law.

This is a great example of how the legalese we experience every day causes people to lose focus on the greater good. You might try the power of semantics — “I’m not asking you to purée her food. I just want you to make her the smoothies she likes.” (Then stock the ingredients that go into the smoothies and the recipes for them.). Sounds much less medical all around. As long as our legal system continues to support such a litigious focus, we sometimes have to just use their “letter of the law” focus against them so that the “spirit of the law” can be served.

Garden Artist – I think you've discovered what I was going to suggest: the particular agency may simply not want to handle dysphagia patients (or doesn't want to handle your dad specifically, for whatever combination of reasons). I've caught reps talking in a misleading way about regulations to avoid refusing a customer request. Sometimes, it's because they don't really understand what is a company practice vs a state or federal regulation. Other times, they want to avoid a discussion about it, so they give the impression that they 'can't' rather than they 'don't want to'.

I puree food every day for my pineapple whip. I hope I'm not breaking some law.

I use these bento-type boxes and write what is inside on a post-it on top.
https://www.amazon.com/gp/product/B004S129AQ/ref=oh_aui_detailpage_o02_s00?ie=UTF8&psc=1
I puree enough of whatever dish and sides that I've made for several meals at a time and then freeze the extras to pull out later. The caregiver that comes at lunchtime just needs to heat it up and serve. It's still a chore to keep up with having pureed, low sodium, low vitamin K meals prepped along with full time work and everything else.

Care I think you are safe as long as you don't sell any. Health Inspectors have not got as far as home kitchens yet.
I do hear though that the kids are no longer allowed to bring in home made goodies. They have to be straight from the store in an unbroken package.

My husband was in Hospice care when he developed pneumonia. He kept coughing, and I thought it was a sign of pneumonia--but I noticed it only happened after meals. After I talked to the Hospice nurse, she advised me to not let him drink water out of a glass--feed him only a teaspoon of water at a time. When I asked why, the nurse stated that he might aspirate the fluid because he has trouble swallowing. I know how much he enjoyed drinking water--I couldn't deprive him! I discussed it with him, and we agreed it was ok to risk death from pneumonia in order to be more comfortable. The nurses advised me to purchase "ThickIt," a powder which could be added to fluids to make them easier to swallow without aspirating. I prepared solutions of thickened water for my husband to drink. I judged my success when he drank without coughing. I noticed that he couldn't tolerate solid food, so I made purees, soups, and protein drinks. The nurses didn't guide me. I figured he needed food, so I needed to find a way to prepare it so he could enjoy it and tolerate it. Now I see that he almost certainly suffered from dysphagia--maybe that is what helped cause his pneumonia. Thanks to everyone for this discussion. I used to feel guilty that I didn't do enough for him (he passed away earlier this year.) Now I'm feeling proud that I helped care for him so he could be comfortable. But I do advise all family members to persist in getting information from the nurses/doctors. And I often would ask 2 different hospice nurses, if I found the first answer wasn't working for me or I couldn't understand how to implement it.

I think it depends greatly on what the agency has as their rules and guidelines.
As soon as someone needs foods thickened an agency may require a "higher level" of care for a variety of reasons.
It is a way to charge you more.
If they are saying that the "regular" caregiver is not trained and they are "just" companion care then they can require that a CNA be in charge of care. This could be for legal reasons or monetary.
Anyone can puree food in most cases as long as the patient can pick up a utensil and feed themselves there is no problem with "level of care" it is when someone has to feed the patient or closely monitor the eating so as to prevent aspiration that is becomes more of a challenge.
This also go to adding a thickener to thin foods. An agency may consider a thickener as a "medication" and at that point they would require a CNA or possibly a nurse.

I would take a look at the agency guidelines and see what it specifically states about food, feeding, pureeing, thickening. If there is nothing written I would question the reason they are giving you and I would begin to interview other agencies or look into hiring a private caregiver.
Private caregivers and do anything you request of them since it is under your direction. Puree food, feed a person, even give medications, dress wounds. As long as they have been trained, taught what to do and are comfortable doing it.

Thanks to everyone who's posted since I last posted - lots of good advice. I just got home from a pureeing session and am ready for some Motrin and a heating pad, but wanted to thank everyone and acknowledge more posts which I'll get to tomorrow.

My private aide with mom said she's getting depressed with her purée food so I arranged for some real food for her tonight - takeout - the report was she was so happy and ate well albeit slowly

MsMadge, that is a real plus for your mom, having personal caregivers allows her some personalized care options, even if it is only occasionally!
Understandably when you are assigned a special diet in the NH they do not even attempt to stray from it, even though some people can handle forbidden items occasionally. My mom always liked her crunchy snacks and never choked on them, so last week I took some potato chips and warily fed her little nickel sized pieces... she gobbled them up!

In MA we can allow the aides to prepare the food but the aides are not allowed to assist in the feeding of anyone with a swallowing problem.

WoW
Mom has trouble lifting her utensils so thank goodness aides can spoon feed her if need be

Cwillie, you know you can't eat just one potato chip

Quick question on the Bento plates/boxes bought from Amazon?

Are these fully microwavable for frozen meals? One set of containers I bought, which began to "fray" after being reheated, were perfectly sized, but the plastic "fraying" was a problem.


When I called the manufacturer, a customer service rep revealed that they are microwaveable, but not for more than 30 seconds. That's not much help for reheating meals.

And unfortunately, that limitation wasn't on any of the containers or the packaging, so I had no way of knowing they were for limited use.

Something that's microwaveable for multiple uses is what I want.

Those Bento containers look perfect, but I wonder if anyone has used them to reheat for several minutes, and whether or not the plastic began to deteriorate as if it was scratched.


I checked out another source, where I could probably buy or order locally, and read that the boxes can be used again, but there's also a disclaimer as to the source of the information. Users would, I think, know better from experience.


Thanks again for all the helpful posts. I'll be back for more individual expressions of appreciation.