MDS Alert

Use this tool to evaluate staff/resident interaction during meals.

Unintended weight loss — sustained or sudden — is an obvious quality indicator for everyone involved in a resident’s care. Make sure you investigate why a resident is losing weight, and look into any easy fixes, like adjusting staff assistance at meal-times and documenting their interactions. With more or better assistance, residents have a better chance of receiving their nutrients, your facility has a better chance of being reimbursed, and quality measures are indicative of quality care.

Check out these eight tips, inspired by a CMS webinar for surveyors. These suggestions are inspired by the document Continuous Quality Improvement For Meals: An Observational Tool, a CMS handout for state surveyors.

Use these measures to conduct your own survey. Use your “fails” to see what areas need improvement to make your facility’s mealtime assistance quality top notch.

1. Make it to the table

Make sure residents are making it to mealtime in the dining room or other central eating location. Besides encouraging socialization, reducing the chance of isolation, and continuing societal norms that help dispel the feeling of institutionalization, having residents eat meals together is also a great way for staff to keep an eye on everyone at one time, in one place.

Score yourself: Over the past seven days, have more than half of the residents able to eat solid food and liquid made it to the dining area at all meals? Give yourself a “pass.”

Go further: If you notice that residents who are capable of eating and drinking aren’t eating meals in these common spaces, find out why. Is Mr. Eyre avoiding mealtime because of his running feud over politics with Mr. D’Urberville? Can you adjust the seating so they don’t have to interact?

Look into other ways to make dining a more pleasant or natural experience. Personalize the dining experience as much as possible within your facility’s abilities and constraints, suggests a 2011 compilation of New Dining Practices from the Pioneer Network in collaboration with the Hulda B. & Maurice L. Rothschild Foundation. Some of their suggestions could be manifested like this:

• Individualize the meal experience. Does Mr. D’Urberville prefer eating alone? Does he eat more when he’s not worried about socializing?
• Observe whether residents are struggling because of the utensils — does therapy have any suggestions to make a spoon easier to hold and manipulate?
• If your facility serves juice in cartons or cups, observe whether one shape is easier to hold and make adjustments accordingly, if possible.
• Use context, too: If Mrs. James barely picks at breakfast but has a hearty appetite for lunch and » » » » dinner, perhaps she would prefer a lighter meal that early in the morning.
• Talk to residents about whether they’re enjoying their meals.

2. Cue the Queue

Check out how staff are interacting with residents during meals. Is staff feeling harried and providing physical assistance to help residents eat more quickly without first pointing out the food item or suggesting a utensil?

Score yourself: If even a single resident receives physical assistance from a staff member without also receiving a verbal reminder to eat (or use a particular utensil or other queue), give yourself a “fail” for this item.

Go further: Stressed-out staff, trying to get residents through their meals as quickly as possible or lacking patience with a particular resident, may jump the gun by providing too much assistance too soon (or consistently). This unnecessary (or too frequent) physical help may make residents more reliant on staff assistance when they could manage fairly well on their own. Plus, residents are more likely to up their food and fluid intakes if they’re being verbally prompted or acting of their own body’s needs.

MDScheck: Your response to Item G0110H (Activities of Daily Living Assistance, Eating) should reflect the level and frequency of staff assistance. For more about G0110H, see page 62 in this issue.

3. Eat a Little, Talk a Little

Residents shouldn’t feel like they’re merely being fed; in most cultures, mealtimes are a crucial time for socializing. While in most facilities, residents eat together, check in to make sure staff are interacting with them as people and not just residents. A simple “How have you been today?” from a staff member goes a long way in ensuring an atmosphere that feels homey and less institutional, and meals are a perfect place to observe both functional and social norms.

Score yourself: Mark yourself “pass” here only if every single resident has an interaction or exchange with staff that is purely social during each meal.

Go further: Part of the sea change of patient-centered care is further focus on patients as people, and conversations and exchanges that occur outside of the medical frame of mind or the staff/resident paradigm play a huge part in helping residents feel like people. If you notice your team members are too focused on making sure residents are eating to sneak in a hello or a line or two of conversation, consider providing a quick reminder or collaborating with whomever trains staff to make interaction with residents a more emphasized part of training.

4. Know Who’s Drinking What, When

Supplemental oral liquid nutrition can help residents put on weight through increased calorie consumption, but make sure residents are receiving these as true supplements (nutrition and calories in addition to what a resident can consume by eating) and not in place of meals.

Score yourself: Evaluate this item by considering how much time staff spends with any resident receiving an oral liquid nutritional supplement during the meal. If staff spend less than five minutes providing assistance with the actual meal and the resident still receives a supplement, give yourself a “fail.”

Go further: Nutritional supplements are most effective for intentional weight gain or nutrition adjustment if they’re given between meals. If a resident is losing weight and receiving an oral liquid nutritional supplement at meals and receiving fewer than five minutes of staff assistance, ineffective or insufficient staff time could be the cause. If possible in your facility, adjust how much time a team member can spend assisting this resident during mealtime, and see if that helps with weight management and nutrient absorption.

MDScheck: Don’t forget to reevaluate item G0110H (Activities of Daily Living Assistance, Eating) if you make any changes.

5. Look Out, Eat Up, Drink Up

Try to catch an unintentional weight-loss issue before it really becomes problematic. You or a team member should observe how much of a meal a resident consumes, and if you’re worried about weight maintenance, see if there’s any correlation between the amount of food consumed and the amount of assistance received.

Score yourself: Give yourself a “fail” if you notice that any resident who consumes less than half of his meal (through your or a team member’s observation) also receives fewer than five minutes of attention from staff.

Go further: Relying on staff for help in a function as basic as eating can be tough for residents who mourn the loss of their independence, but documenting any changes in food consumed and staff attention received is important for the medical record, as well as reimbursement and care-planning. Careful observation and comprehensive documentation provides helpful benchmarks and establishes a timeline that could be crucial down the road.

6. Check on Staff Knowledge

Make sure staff knows what they’re looking for, including any crucial indicators that a resident isn’t receiving the appropriate nutrition or amount of food or liquid, as well as clinically significant markers.

Score yourself: Give yourself a “fail” if there’s a discrepancy between direct observation and staff notes or the clinical record, in regard to the amount of food consumed; pay extra attention if one source suggests less than 50 percent and the other more than 60 percent.

Go further: Do your team members understand the threshold for the measure “clinically significant?” If their records or observations don’t correlate with your observations of meals or the clinical record, you can have a discussion with staff to make sure they understand how to evaluate consumption and explain that the difference in their notes really has an effect on residents’ care planning.

7. Find Out if Food Preferences are an Issue

As residents have no control over the menu, it makes sense that a resident might not eat much, if any, of a meal that she dislikes.

Score yourself: If a resident eats less than 50 percent of both food and fluid items (based on staff observation) and is not offered a substitute by staff, give yourself a “fail.”

Go further: Residents may not feel comfortable speaking up and asking for an alternative meal, so work on training staff to make those observations. Getting to know residents’ normal eating habits sets a great baseline to know when something is wrong, even when that “something” is disliking that particular meal. Make sure your team members note whether substitutions were offered, and whether the resident chose to substitute an entire meal or a particular item (for example, requesting a peanut butter and jelly sandwich instead of the meatloaf), and whether the substitution made a difference in intake.

8. If It’s Not Documented …

… it didn’t happen. You know this, but does your entire staff? It’s crucial that documentation is accurate, for the sake of the clinical record and for the MDS and reimbursement. Compare what you or team members observe and record daily to what you or other team members see and record daily.

Score yourself: If the clinical record or other notes say that a resident received assistance at mealtime but direct observation shows that a resident received less than five minutes of help, give yourself a “fail.”

Go further: Work with staff to verify that observations at mealtime are being recorded. Can you build in 10 minutes after meals for staff to jot down notes? If you can make it to mealtime, make your own observations and suggest to your team members that you all quiz each other to check to see whether your observations align.

Read more: http://surveyor.vo.llnwd.net/o45/data/1058/CQI_for_meals_observational_tool_instructions.doc

http://surveyor.vo.llnwd.net/o45/data/1101/NewDiningPracticeStandards.pdf.