Regulation & Survey Process Related to

Nutrition & HydrationBrenda Buroker, RN, ISDH Survey ManagerDonna Downs, RN, ISDH Area Supervisor

Indiana HealthcareLeadership Conference

March 31, 2011

REGULATION – F325

• 483.25 (i) Based on a resident’s comprehensive assessment, the facility must ensure that a resident –

483.25(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

483.25(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 AppearanceHeightWeight

Current Standard of Practice for WeighingAdmission /ReadmissionWeekly for first 4 weeksMonthly Significant Change in Condition

ASSESSMENT

Food and Fluid intakeAltered Nutrient intake

Inability to consume meals provided

Insufficient availability of food

Environmental factorsMedicationsDisease or condition

• Chewing abnormalities

• Swallowing abnormalities

• Functional ability• Medications• Goals and prognosis• Laboratory Test

Serum AlbuminPre-albumin

ANALYSIS & EVALUATION

RAI InformationInformation from assessmentReview / Analyze informationIdentify or determine status

Risk for unplanned weight lossAble to maintain acceptable parameters

WEIGHT LOSS PARAMETERS

INTERVAL SIGNIFICANT SEVERE

1 month 5% >5%

3 months 7.5% >7.5%

6 months 10%>10%

CARE PLANNING & INTERVENTIONS

Resident Choice Meet Nutritional

NeedsDiet LiberalizationWeight – Related

InterventionsWeight GainEnvironmental

FactorsAnorexiaWound Healing

Functional FactorsChewing &

SwallowingMedicationsFood Fortification &

SupplementationFluid & ElectrolyteAppetite StimulantsFeeding TubesEnd-of-Life

MONITORING

Identifying and Reporting InformationLevel of consciousness & functionPain or discomfortFluctuating appetiteNausea or GI symptoms

Emergence of new risk factorsAcute medical illnessPressure 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 appearanceDining observationsDelivery of careServing of foodResponse to resident’s needsDifferences between observations and care

plan /interventions

INVESTIGATIVE PROTOCOL INTERVIEW

RESIDENT, FAMILY OR REPRESENTATIVENecessary equipmentPreferencesChoices / SubstitutionsSupplements / SnacksRefusal of therapeutic approaches

explained

INVESTIGATIVE PROTOCOL INTERVIEW

STAFF – (Direct care & interdisciplinary team members)

Intake monitored and reportedNutritional interventionsCommunication related to care plan and

interventionsReport of changes

INVESTIGATIVE PROTOCOL RECORD REVIEW

Evaluated & analyzed nutritional statusIdentified nutritional riskInvestigated causes of impaired nutritional

statusIdentified & implemented nutritional

interventionsIdentified RAI triggeredEvaluated effectiveness of interventionsMonitored & 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 TAGSF150 – Resident RightsF272 – Comprehensive

AssessmentsF279 – Comprehensive

Care PlansF280 – Comprehensive

Care Plan RevisionF282 – Provision of

Care in Accordance with the Care Plan

F327– HydrationF328 – Special Needs

F329 –Unnecessary Drugs

F353 – Sufficient StaffF361 – Dietary ServicesF362 – Standard

Sufficient StaffF385 – Physician

ServicesF500 – Use of Outside

ResourcesF501 – Medical DirectorF522 – Quality

Assessment & Assurance

REGULATION – F327

483.25(j) Hydration. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health

INTENT – 483.25(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 ccException is renal / cardiac residents

PROBES

• Clinical signs of insufficient fluids observed

• Laboratory results – abnormal

• Facility actions• Identify risk factors• Care provided• Alternative treatment

QUALITYINDICATOR

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 residentsADMISSION SAMPLE – up to 30 residents

Current or Closed RecordsFood choices – not part of Admission Sample

criteriaTerminal Diagnosis

WEIGHTS REVIEWEDTimeframe in the facilityPotential trigger if weight loss occurred

QIS -- RECORD REVEIW

Planned weight loss programHeight recordedDate & weight closest to admissionDate & weight closest to 15 days after

admissionDate & weight closest to day 30 after admissionDate & weight closest to day 60 after admission

QIS

ASE-Q calculates the requested dates and percentage of weight loss.

Critical Elements PathwayNutrition -- noneHydration -- 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 PlanInterventions Implementation Individual Needs – identified and addressedPlan/Interventions are successfulRevisions if necessary

THANK YOU