Regulation & Survey Process Related to Nutrition & Hydration Brenda Buroker, RN, ISDH Survey Manager Donna Downs, RN, ISDH Area Supervisor Indiana Healthcare Leadership Conference March 31, 2011

REGULATION – F (i) Based on a resident’s comprehensive assessment, the facility must ensure that a resident – (i)(1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that it is not possible; and (i)(2) Receives a therapeutic diet when there is a nutritional problem.

INTENT Provide nutritional care and services to each resident, consistent with the comprehensive assessment; Recognizes, evaluates, and addresses the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition; and Provides a therapeutic diet that takes into account the resident’s clinical condition, and preferences, when there is a nutritional indication.

ASSESSMENT General Appearance Height Weight Current Standard of Practice for Weighing Admission /Readmission Weekly for first 4 weeks Monthly Significant Change in Condition

ASSESSMENT Food and Fluid intake Altered Nutrient intake Inability to consume meals provided Insufficient availability of food Environmental factors Medications Disease or condition Chewing abnormalities Swallowing abnormalities Functional ability Medications Goals and prognosis Laboratory Test Serum Albumin Pre-albumin

ANALYSIS & EVALUATION RAI Information Information from assessment Review / Analyze information Identify or determine status Risk for unplanned weight loss Able to maintain acceptable parameters

WEIGHT LOSS PARAMETERS INTERVAL SIGNIFICANT SEVERE 1 month5% >5% 3 months7.5% >7.5% 6 months 10%>10%

CARE PLANNING & INTERVENTIONS Resident Choice Meet Nutritional Needs Diet Liberalization Weight – Related Interventions Weight Gain Environmental Factors Anorexia Wound Healing Functional Factors Chewing & Swallowing Medications Food Fortification & Supplementation Fluid & Electrolyte Appetite Stimulants Feeding Tubes End-of-Life

MONITORING Identifying and Reporting Information Level of consciousness & function Pain or discomfort Fluctuating appetite Nausea or GI symptoms Emergence of new risk factors Acute medical illness Pressure ulcer Fever

EVALUATION Care plan and current interventions: Effective in attaining identified nutritional & weight goals Nutrition-related interventions and/or goals need to be modified Explanation of any decisions to continue interventions if nutritional decline

INVESTIGATIVE PROTOCOL OBSERVATIONS Resident appearance Dining observations Delivery of care Serving of food Response to resident’s needs Differences between observations and care plan /interventions

INVESTIGATIVE PROTOCOL INTERVIEW RESIDENT, FAMILY OR REPRESENTATIVE Necessary equipment Preferences Choices / Substitutions Supplements / Snacks Refusal of therapeutic approaches explained

INVESTIGATIVE PROTOCOL INTERVIEW STAFF – (Direct care & interdisciplinary team members) Intake monitored and reported Nutritional interventions Communication related to care plan and interventions Report of changes

INVESTIGATIVE PROTOCOL RECORD REVIEW Evaluated & analyzed nutritional status Identified nutritional risk Investigated causes of impaired nutritional status Identified & implemented nutritional interventions Identified RAI triggered Evaluated effectiveness of interventions Monitored & modified approaches as needed

INVESTIGATIVE PROTOCOL Assessment & monitoring Care Plan Care Plan Revision Facility Practices

INVESTIGATIVE PROTOCOL COMPLIANCE Assessed and identified nutritional risk factors Analyzed the assessment information Provided therapeutic diet when indicated Defined and implemented nutritional interventions related to needs, choices, goals & standards of practice Monitored & evaluated response and revised as necessary

INVESTIGATIVE PROTOCOL POTENTIAL ASSOCIATED TAGS F150 – Resident Rights F272 – Comprehensive Assessments F279 – Comprehensive Care Plans F280 – Comprehensive Care Plan Revision F282 – Provision of Care in Accordance with the Care Plan F327– Hydration F328 – Special Needs F329 –Unnecessary Drugs F353 – Sufficient Staff F361 – Dietary Services F362 – Standard Sufficient Staff F385 – Physician Services F500 – Use of Outside Resources F501 – Medical Director F522 – Quality Assessment & Assurance

REGULATION – F (j) Hydration. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health INTENT – (j) The intent of this regulation is to assure that the resident receives sufficient amount of fluids based on individual needs to prevent dehydration.

RISK FACTORS Coma /decreased sensorium Fluid loss and increased fluid need Fluid restriction (renal) Functional impairments Dementia Refusal of fluids

PROCEDURE Identify residents at risk General guidelines for determining baseline daily fluids needs: Multiply body weight in kg (2.2 lbs = 1kg) by 30 cc Exception is renal / cardiac residents

PROBES Clinical signs of insufficient fluids observed Laboratory results – abnormal Facility actions Identify risk factors Care provided Alternative treatment

QUALITY INDICATOR SURVEY (QIS)

QIS -- INTERVIEW RESIDENT INTERVIEW: Are you able to participate in making food choices/preferences? Does the food taste good and look appetizing? Is the food served at the proper temperature? Do you receive the fluids you want between meals? Do you have any chewing or eating problems(could be due to no teeth, missing teeth, oral lesions, broken or missing teeth)?

QIS – FAMILY INTERVIEW FAMILY INTERVIEW: Does the facility honor the resident’s preference on what he/she eats or drinks? Does the resident receive the assistance with meals that he/she needs?

QIS -- STAFF INTERVIEW STAFF INTERVIEW: Is the resident receiving a nutritional supplement, defined as a prescribed high protein, high calorie, nutritional supplement between or with meals? There must be documentation in the clinical record.

QIS SAMPLE RECORD REVIEW CENSUS SAMPLE – up to 40 residents ADMISSION SAMPLE – up to 30 residents Current or Closed Records Food choices – not part of Admission Sample criteria Terminal Diagnosis WEIGHTS REVIEWED Timeframe in the facility Potential trigger if weight loss occurred

QIS -- RECORD REVEIW Planned weight loss program Height recorded Date & weight closest to admission Date & weight closest to 15 days after admission Date & weight closest to day 30 after admission Date & weight closest to day 60 after admission

QIS ASE-Q calculates the requested dates and percentage of weight loss. Critical Elements Pathway Nutrition -- none Hydration -- yes

HYDRATION CRITICAL ELEMENTS Use this protocol for a sampled resident with the potential for or identified with, hydration issues, such as not being able to reach, pour, and drink water without assistance.

OBSERVATIONS Determine whether staff provide are in accordance with the care plan. Note whether the resident’s level of alertness and functioning permits oral intake, whether assistive devices and call bells are available for the resident who is able to use them, and whether staff provide assistance for the resident.

Determine whether containers have fresh water, and drinking cup or straw and are available in the room and accessible to the resident. Determine whether fluids are provided at meals and the resident is encouraged to drink them. Determine how residents with fluid restrictions are monitored.

KEY POINTS – Traditional & QIS DOCUMENTATION: Assessment Care Plan Interventions Implementation Individual Needs – identified and addressed Plan/Interventions are successful Revisions if necessary

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