Long-Term Care Survey Alert

6 tough clinical issues that your dietary program might just solve.

How can your facility target its nutrition program to promote the best clinical and survey outcomes? Interdisciplinary experts count the ways:
 
1. Wound healing. If the nutritional piece is missing from your wound program, surveyors are more likely to cite F314 even if you're doing everything else right. "The resident needs enough protein, calories, fluids, vitamin C and zinc, etc., to heal," although the dietary plan has to be individualized, says Maria Whybark, adjunct professor of nutrition at Madonna University in  Livonia, MI. For example, residents with kidney disease can't tolerate as much protein as other residents. To find out what surveyors expect to see facilities do to assess and meet wound care patients' dietary requirements, see the October 2003 Long-Term Care Survey Alert.
 
2. Falls. Residents with poor nutrition are more likely to fall, because they have less strength and muscle mass, Whybark explains. She also points to research done in emergency rooms showing that a lot of elderly people admitted for falls are dehydrated. And once someone is dehydrated, they get more urinary tract infections, which lead to delirium and confusion and, hence, more falls.
 
3. Fractures. Calcium and vitamin D provide the "backbone" in terms of preventing and treating osteoporosis. "The best way to get calcium is by diet, so the dietitian should calculate calcium requirements and recommend calcium-rich foods," suggested Jan Maby, a nurse and doctor of osteopathy, presenting at the National Association of Directors of Nursing Administration in Long-Term Care conference in Cincinnati in June.  (A list of calcium-rich foods can be printed at www.tdh.state.tx.us/osteo/calcium.htm.)  

Residents may also benefit from vitamin D and calcium supplementation. Women aged 84 who received the recommended supplementation for 18 months had 43 percent less hip fractures than a control group, according to a study reported in the New England Journal of Medicine.
 
4. Urinary incontinence. Everyone knows that caffeine sends people trotting to the bathroom, which translates into more toileting accidents and urge incontinence (and more falls). "Yet surveyors might question a facility that halted caffeine across-the-board, as it is such a lifestyle issue - people love their coffee or tea," Whybark cautions. Good Shepherd Services has stopped all caffeine in its nursing facility (residents get decaf beverages and no caffeinated sodas). "But if a resident really wants caffeinated coffee or colas, etc., we do accommodate the request," reports Tom Lohuis, operations director and nursing home administrator for Good Shepherd in Seymour, WI. "We also avoid serving grapefruit juice because it's acidic, irritates the bladder and interferes with some medications," Lohuis adds.
 
Tip: The way in which the facility prepares coffee and tea can have a major impact on the amount of caffeine residents receive. (To print a chart listing caffeine content in OTC medications, various types of coffee and tea, soft drinks and foods, go to www.cspinet.org/new/cafchart.htm.)
 
5. Depression. Enjoyable, nutritious food increases a resident's energy level - and it's a major source of emotional satisfaction. "Food is one of the last pleasures to go, but in a nursing home the person often receives unfamiliar foods or familiar foods in an unfamiliar format," Whybark says. A selected menu gets around this problem and increases a resident's sense of choice (which also helps depression). But encourage the person to actually choose her menu, which someone with depression may be reluctant to do. "That approach will work best for someone who is cognitively intact and can remember what they selected," Whybark notes. "But even someone with cognitive impairment will know if they don't like a food choice."
 
6. Bowel Problems. The right fiber intake and fluid intake promotes bowel regularity, which means less urinary and bowel incontinence and fecal impaction (the latter is a sentinel event). The recommendation for healthy individuals is 25 grams of fiber a day, and the person has to drink about eight glasses of water to accompany the fiber, Whybark says. "But an elderly person with medical complications may not be able to tolerate this level of fiber, so increase a resident's fiber intake gradually to a level they can tolerate."
 
Also keep in mind that residents may end up with a fecal impaction if you increase fiber without adding enough water, warns Annette Fleishell, vice president for clinical services at Joanne Wilson's Gerontological Nursing Ventures in Laurel, MD.  Tip: "Residents on pain management who develop constipation can find relief from a bowel management protocol and increased hydration," Fleishell adds.
 
Do you have a resident with diarrhea or chronic loose stools? Check to see if she's chewing raw vegetables and fruits well, Whybark suggests. Residents with chronic diarrhea may also have lactose intolerance or celiac disease. Tip: Studies show that yogurt and fermented drinks containing "good" bacteria help inflammatory bowel disease.