Indiana Healthcare Leadership Conference March 31, 2011

1. Indiana HealthcareLeadership ConferenceMarch 31, 2011 Regulation & Survey Process Related to Nutrition & Hydration Brenda Buroker, RN, ISDH Survey Manager Donna Downs, RN, ISDH Area Supervisor

2. 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.

3. 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.

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

5. 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

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

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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. INVESTIGATIVE PROTOCOL • Assessment & monitoring • Care Plan • Care Plan Revision • Facility Practices

16. 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

17. 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

18. 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.

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

20. 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

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

22. QUALITY INDICATOR SURVEY (QIS)

23. 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)?

24. 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?

25. 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.

26. 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

27. 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

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

29. 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.

30. 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.

31. 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.

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

33. THANK YOU