MDS Alert

These expert strategies will improve resident and survey outcomes.

Surveyors will be targeting nutritional assessment as the linchpin for care planning under the revised F325 tag. And the MDS can play a key role in identifying residents at risk for nutritional problems and unintended weight loss. "The nutrition professional can use the MDS information to complete a comprehensive nutrition assessment," says Brenda Richardson, MA, RD, LD, CD, a nutrition expert in Pekin, IN. "This also helps in providing an assessment that supports the RAI process," she adds. In particular, consider these MDS sections and items:

• Customary routine (Section AC). As part of that assessment, the nurse assessor could identify food preferences, meal patterns, and use of alcoholic beverages, etc., says Richardson. "As we move toward person-centered care, it's important to get that information from the resident or a family person or someone who knows the resident, if he can't communicate the information."

• Advance directives (Section A10). "Advance directives should be a part of the admissions process where you see if the resident or his responsible party has an advance directive or wants one," says Christine Twombly, RN, a consultant with Reingruber & Co. in St. Petersburg, FL. But addressing that item when you complete the MDS provides a "good double check to make sure the issue has been addressed [or updated], if needed since the documentation must be present in the record in order to code this item on the MDS," adds Twombly. Absence of documentation should trigger a discussion between the facility staff and resident or family/responsible party about the resident's wishes, she adds. Also address and resolve any variances between the resident's current stated wishes and what's documented in the record, advises Twombly.

• Cognitive deficits (Section B). "CNAs are for the most part the ones who can really provide the most accurate information about a resident's food preferences if the person has dementia and can't make those known," says Richardson. "The CNAs know if the resident accepts particular foods and eats them."

• Functional deficits (Section G). F325 talks about looking at residents' ADLs related to nutrition, Richardson notes. "Section G will include information about whether the person requires ADL help with eating." Also look at the person's range of motion, she advises. "Does he have functional limitation with upper extremity use? Does that affect the person's ability to feed himself?"

• Mood indicators (Section E). Depression can affect appetite, which is why it's critical to look at mood issues when completing the MDS.

Follow up on someone triggering as having mood indicators to see if he is eating enough or has any signs of weight loss, Richardson advises.

• Bowel health (Section H). "The dietitian should be involved when a resident has gastrointestinal issues, such as irritable bowel, diarrhea, or constipation," Richardson advises.

• Diagnoses (Section I). Look for any condition that affects a person's ability to feed himself or that alters appetite or nutritional requirements, such as hemiplegia, multiple sclerosis and Parkinson's disease, says Richardson. The F325 guidance mentions arthritis-impaired movement. Of course, diabetes mellitus would also be on the list as requiring nutritional assessment and care.

Among other conditions, the Nutritional Status RAP guidelines cite chronic obstructive pulmonary disease (COPD) as a condition that "increases calorie needs and can be complicated by an elevated fear of choking when eating or drinking."

• Fluid status, falls, pain (Section J). If the person has output exceeding intake, that's a red flag for hydration issues. Also take a look at whether a resident is falling. There is a higher incidence of falls especially related to hydration, Richardson cautions. Also, as a person loses muscle mass, he may be more prone to fall, she adds.

Pain can significantly affect a person's appetite or ability to feed himself. The revised F325 guidance specifically mentions oral pain and neuropathic pain.

Oral/nutritional status (Section K): Assess for and code whether the person has a chewing problem, swallowing difficulty or mouth pain coded in K1(for a free article in Long-Term Care Survey Alert on novel approaches to promote oral and dental health, e-mail the editor your request at KarenL@Eliresearch.com).

Know how to code weight loss: Code the resident at K3a as having a 5 percent or greater weight loss in the last 30 days -- or a 10 percent or greater loss in the last 180 days (see the previous page for the calculation).

Warning: F325 also refers to insidious weight changes, which occur when a resident loses a pound each month, for example, showing a gradual weight loss over time, Richardson notes. When completing the MDS, this type of weight loss may not trigger on the quality indicator, she says, even though the resident is on a downward decline weight-wise. But surveyors expect facilities to identify these people and provide appropriate assessment and intervention, she advises.

Great point: Bariatric patients can also be malnourished, advises Richardson. For example, if someone is clinically obese, "make sure he's consuming enough protein to heal a pressure ulcer," she counsels. "Also, if the person is losing weight as part of a planned dietary effort," that's fine. But if he quits eating well and is losing weight, assess what's going on. (Code a planned weight change program at K5h.)

Make sure to carefully complete K4 (nutritional problems) and K5 (nutritional approaches). If you've coded that the person complains about the taste of many foods (K4a), keep in mind that loss of taste and smell can really affect appetite. "It's important to assess for that and address this by using flavor enhancers, or additional herbs or spices," says Richardson.

The facility needs an accurate way to assess food intake and a validation system to ensure the medical documentation is on the mark (for a dining observation tool that managers can use to see if CNAs are recording meal intake correctly, see the Vol. 6, No. 5 MDS Alert, page 53, available in the Online Subscription System). "Residents may eat less than you think they need to and still do OK -- that's why you should monitor both food intake and weight," advises Richardson.

• Pressure ulcers (Section M). Pressure ulcers can cause someone to go into a hypermetabolic state in which the body pulls from lean body mass for energy, cautioned Becky Dorner, RD, LD, in an Eli Research-sponsored audioconference on nutrition and pressure ulcers. That's "why we add extra protein and calories" for people with pressure ulcers. You have to provide sufficient calories at all stages of healing, she noted.

Identify and document whether the resident is actually eating what's identified as a therapeutic intervention, such as additional protein, advises Reta Underwood, a survey consultant in Buckner, KY.

Clinical gems: There are nutritional products such as ProStat and others that provide very concentrated amounts of protein and calories in an ounce of fluid, says Richardson.

Also, activities can be part of a nutritional plan, advises Underwood.

• Intake and output (Section P). Code whether the resident is on intake and output. "If the SNF identifies someone at high risk for dehydration or weight loss, it's important to monitor and document the person's fluid intake and also carefully monitor his nutritional intake," Richardson says.

• Rehab therapy and restorative nursing (Section P). If the resident has a swallowing problem or ADL deficit affecting eating, is restorative nursing and/or rehab therapy on the case?

Resource: For an article in Long-Term Care Survey Alert on how medications can affect appetite and a list of common meds known to suppress appetite, e-mail the editor at KarenL@Eliresearch.com.