Long-Term Care Survey Alert

If your facility is implementing nontraditional dining, make sure surveyors dont end up dishing out F tags rather than accolades for your efforts.

As a first step to protect yourself, identify the outcomes the facility hopes to achieve by moving to family-style or buffet dining, says Megan Hannan, a consultant with Milwaukee-based Action Pact, which works with facilities to improve residents quality of life and autonomy.

Are you implementing the change to address overcrowding in the dining room or to provide a more social or enjoyable dining experience? Do you have a lot of people complaining about food or losing weight?

Secondly, dont use a "cookie cutter" approach advocated by consultants or another facility to implement the change. "You have to think through how the program or approach will work in your facility," Hannan emphasizes. For example, one facility got a sanitation tag because it placed its buffet in a location with no handwashing facility nearby, reported Carmen Bowman, a surveyor who presented during the Centers for Medicare & Medicaid Services recent Webcast on improving quality of life in nursing homes.

New dining approaches can improve residents quality of life and nutrition, but they also pose new infection control challenges. For example, a facility with a breakfast buffet got an F371 tag for kitchen sanitation when a chef cracked eggs over an open griddle and forgot to wash his hands or change gloves, Bowman told Webcast viewers.

Also, facilities that allow residents to custom order their eggs "over easy" can end up with an infection control tag for potential salmonella food poisoning. "Using pasteurized shell eggs for short-order breakfasts can sidestep this problem," Bowman suggested. More food vendors are selling the disinfected eggs nowadays.

Meadowlark Hills Retirement Community in Manhattan, KS, which implemented family-style dining for its SNF residents, had to think through infection control issues in an entirely new way, reports Executive Director Steve Shields.

"As we began to blend roles of our staff members who now move from task to task in a household, such as meal preparation to personal care, we had to make sure they washed their hands and used gloves appropriately," Shields says.

Meadowlark staff members also sit at the family-style table with residents, not only to help residents who need assistance but also to keep an unobtrusive eye out for potential infection control issues. For example, a resident might put his finger in the food to sample it or use his own spoon to dish out food, just as family members might do at home. In such a case, the staff member quietly replaces the contaminated food and the meal continues.

When implementing family-style dining, facilities must still ensure food leaves the kitchen at 140 degrees Fahrenheit. "There is no temperature requirement for food on the plate," CMS Bowman advised. "But if the food sat on the table and became unpalatable especially if residents complained the facility could get an F tag."

Food left on a steam tray or buffet too long can also net a facility an F tag. "Facilities serving buffet-style meals often cook food in batches to avoid such problems," Bowman suggested.

Some providers have abandoned buffet-style dining because the last residents in line ended up with cold food. "One solution is to provide two identical but smaller buffet tables so people can move through more quickly," Hannan says. "Then you put the desserts on a common table."

Surveyors will also keep an eye out for avoidable weight loss in facilities offering family-style or buffet dining because these approaches allow residents to control their own food portions.

"Surveyors will check to see that the facility staff has done everything they can to prevent weight loss within a framework that supports the residents independence and dignity," Bowman explained. So expect surveyors to check out the care plan to explain an individual case of weight loss. "For example, have staff encouraged the resident to take bigger helpings or second servings?" Bowman acknowledged, however, that staff cannot force residents to eat. "And some residents seem to be overwhelmed by too much food on their plates," she said.

Family-style dining usually improves residents appetites even those who require pureed diets. For example, Meadowlark seats residents on special diets at the family table along with everyone else. The staff garnishes pureed entrees to make them visually appealing and puts them on the table along with the regular foods.

The residents on regular diets are free to sample the pureed dishes, which might include salmon mousse or beef with enhanced flavors. "Contrast that approach to the traditional one where residents get pureed foods served in little igloo shapes on their plates," Shields says.