MDS Alert

Know when to move to Plan B to prevent weight loss.

A one-size-fits-all approach to providing dining assistance and interventions will squander staffing efforts -- and fail to identify the underlying reason that someone isn't consuming adequate food and fluids.

Surprising findings: Researchers John Schnelle, PhD, and Sandra Simmons, PhD, have found that only about half of residents with poor mealtime intake will eat significantly more if you give them quality staff assistance, including social interaction and alternative food or drink items if they don't like what's served. (For a tool that can help identify residents who aren't eating well and need more assistance, see p. 53.)

To identify who will benefit from more or better-quality dining assistance, implement a two-day trial of mealtime feeding assistance where you assign a staff member to work with two to three residents at the same time, Simmons suggests. To be efficient, group them together at the table. Give them good quality assistance based on the components identified in the dining observation tool on p. 53, which will also allow you to quantify whether they are eating more. If their oral intake increases, those are the residents who should continue to get assistance during meals, Simmons says.

Boost staff efficiency: To ensure staff has the time to provide more meal assistance, Annette Kobriger, RD, CD, MPH, MPA, advocates using a team approach in the dining room where other disciplines help the nursing assistants with the dining process. "For example, activities staff can transport residents, and other staff people can deliver and set up the tray or sit and visit with the resident for a few minutes," adds Kobriger, a nutritional consultant in Chilton, WI.

Move to Plan B for residents who don't increase their mealtime consumption when they receive more mealtime assistance. You may be able to increase these residents' daily caloric and fluid intake by giving them a variety of snacks between meals, including juices, yogurts, puddings, smoothies and finger foods, Simmons says.

Combat this myth: Some nursing facility staff believe that providing snacks will cause residents to eat poorly at mealtimes. Simmons finds, however, that residents with poor intake are often the ones who eat very little at any one sitting. And if you give them more opportunities to eat, they will consume a small amount of food and fluids each time, resulting in an overall improvement in caloric intake, she says.

Beware giving supplements at mealtime: The dining observation tool (p. 53) also asks the observer to check whether the resident received supplements, such as Ensure or Boost at mealtime. Ideally, residents should receive supplements ordered three times a day in between meals -- not during them. Simmons has observed many residents who eat very poorly because they receive minimal or no staff attention to encourage them to eat. Then at the end of the meal, staff gives them the supplement. "Minimally, residents should receive more staff attention to promote consumption of the served meal and be offered an alternative to the served meal" before staff offer a supplement as a meal substitute, Simmons says.

About 5 to 10 percent of the nursing home population won't eat and will lose weight no matter what intervention staff tries, says Schnelle. Most of these residents are near the end of life. One option in that situation is to start tube feedings, but most residents and their families don't want to do that, he says.

"Artificial nutrition is usually viewed as a temporary intervention to get someone through an acute episode, such as pneumonia or infection, until the illness passes," Schnelle advises. "The intervention is considered most defensible in that type of situation; it's not considered defensible as a long-term intervention unless someone prefers it."