Long-Term Care Survey Alert

Take this approach and let your outcomes speak for themselves.

Dietary-related tags include a whole menu of deficiencies - and you can bet surveyors will be dishing them up this year more liberally than ever.
 
The HHS Office of Inspector General's 2004 work plan says nursing home providers aren't "getting it" when it comes to meeting residents' nutritional needs, in spite of the nutrition-related survey investigative protocols implemented years ago.
 
Yet there's actually a simple recipe for promoting residents' optimal nutritional outcomes, and that is to encourage residents to enjoy foods they like and to eat as normally as their conditions allow.    Facilities that stay true to that simple formula tend to have residents with less unintended weight loss and a better quality of life.
 
For example, do you make the most of meals that residents eat the best? Do a little survey to see when your residents tend to have the heartiest appetites. Then pack those meals with extra calories, protein and other nutrients. For example, if a resident devours his breakfast, serve an extra orange juice and double helpings of eggs and cereal.
 
"Residents typically eat well at breakfast and lunch," says Debra Miller, RD, LD, director of dietary services for Heritage Enterprises Inc. in Bloomington, IL. Thus, Heritage menus provide two-thirds of the recommended daily allowance (RDA) at these two meals, which is also the time of the day when the majority of staff is in the buildings. "By evening, the residents are tired. So the evening meal is designed to satisfy the resident's hunger and make sure he isn't hungry during the night," she says.

Develop a QA Checklist
 
Some facilities devise great nutritional care plans but then they don't implement them consistently. To prevent this problem, devise and use a quality assurance checklist for mealtimes, suggests Annette Kobriger, a long-term care nutritional consultant and principal of Kobriger Presents in Chilton, WI. Failure to follow the plan most often occurs in the dining room, she says. "For example, you'll see where the resident doesn't get his special utensils on the tray - or he gets chicken when he's indicated he doesn't like chicken," she says. Tip: As a readymade QA checklist, use the dining and food services survey investigative protocol, Kobriger suggests You can download and print the survey investigative protocol at http://cms.hhs.gov/manuals/pub07pdf/AP-P-PP.pdf (p. 47). Also, make sure the diet ordered by the physician matches the diet order on the tray card.

Think Outside the Menu
 
Don't be afraid to use nontraditional styles of dining and what might seem like "unhealthy" snacks. "Many facilities have moved to buffet-style dining where residents put less on their plates ... but don't lose weight," says Diane Atchinson, RN-CS, MSN, ANP, president of DPA Associates in Kansas City, MO (for tips on how to monitor buffet meal intake, see the story "Resident Nutrition").
 
Nursing homes are also realizing that the expensive supplements they provide between meals often go untouched by residents. "As a result, providers are switching to snacks that residents really want and enjoy, such as a chocolate peanut butter cup," Atchinson reports.
  
Meadowlark Nursing Home in Manhattan, KS eliminated unintended weight loss when it moved to households where residents eat at family-style tables and/or when they wish. "If the food is appetizing and you get what you're hungry for - and staff sit with you at the table - you're going to want to eat more,"
points out Steve Shields, administrator of the facility.

Rethink Restricted Diets
 
Liberalized diets can enhance residents' quality of life and nutritional status, according to a position statement by the American Dietetic Association. That's not to say that some residents shouldn't receive specialized diets - for example, a renal diet. Or an obese resident might agree to a calorie-restricted diet.
 
Yet, an elderly resident restricted to a 2-gram sodium diet might not find the food tasty enough to eat. And most diets served in nursing homes only contain about 4,000 mg. of sodium without adding table salt, Miller notes. So if a resident consumes half of his meals, he's only getting about 2,000 mg. of salt anyway - and at least he's eating and enjoying his food and supplements, and may maintain his weight.
 
In addition, a diabetic diet doesn't make sense for an 85-year-old resident at risk for wounds who tends to lose weight, Miller adds. "Sometimes we have to educate residents' families about this, too, as the diet protocols have changed over the years," she notes. "For example, the diabetic diet is now based on counting carbohydrates." Tip: Encourage clinicians who do order a restricted diet to consider the resident's food preferences, weight status and amount of food consumed.

Define Goals for Tube Feeding
 
Surveyors will want to know if tube feedings are medically necessary for a particular resident. "The goal is for the resident to eat the highest level of food possible at the table as normally as possible," says Miller. "And if the resident can't do that, you want to identify why," Miller advises. For example, is the resident's need for enteral nutrition temporary due to chemotherapy or does the resident require ongoing tube feedings? Can the staff transition the resident slowly back to eating more normally? When Heritage transitions the resident back to food, the staff has the resident eat during the day, for example, and then runs the tube feeding from 6 p.m. to 4 a.m. "That gives the gut some rest time, and the resident is usually hungry for breakfast," Miller says.
 
Even residents completely dependent on enteral nutrition can enjoy "pleasure foods," such as popsicles or other frozen treats. But make sure the ordering clinician clearly specifies (preferably by consulting with the speech therapist) what foods the resident can manage safely, cautions John Lessner, attorney with Ober/Kaler in Baltimore, MD. Survey Tip: Monitor quality indicator No. 14 (prevalence of tube feedings). If it's outside the norm, figure out why and be able to explain it to the surveyors. If you don't see a clinical rationale, then talk to the physician and dietitian about making changes to residents' nutritional care plans.