Nutrition is more than the MDS, section K: If you think this information is all you need to monitor and meet residents' nutritional needs, think again. (Feature Article).

After practicing as a registered dietitian for 20-years and understanding the importance of nutrition in long-term care, I am amazed to still see nursing facilities not appropriately identifying residents who are nutritionally at risk. In the past several years, I have been directly involved with helping many facilities correct survey deficiencies relating to nutrition and hydration. These facilities, prior to their surveys, thought that their nutritional programs were effective. Needless to say, facility staff were surprised and alarmed to learn that because residents were not being identified as nutritionally at risk, actual harm and even death were occurring.

Resident nutrition and hydration are--and should be--closely scrutinized by state and federal surveyors. Malnutrition in elderly populations is associated with poor clinical outcomes and is an indicator for increased mortality. Residents with severe malnutrition are at higher risk for a variety of complications, and conversely, a number of chronic medical conditions are associated with increased risk of malnutrition. (1)

So it is disturbing to find that the number one reported survey deficiency across the nation in the year 2000 for Medicare and Medicaid-certified nursing facilities (28.8%) was F371: Food Sanitation and Safety. And Nutrition F325--the tag that ensures that residents maintain acceptable parameters of nutritional status, given their clinical condition and interventions employed--was a cited deficiency in almost one in ten facilities in 2000. Revisions of the State Operations Manual for P325 and F371 are forthcoming, and will no doubt incorporate nutritional "best practice" guidelines to aid facilities in their provision of services.

Facilities with successful nutritional programs all understand and support two primary principles, but some facilities are misguided by some common misconceptions. Recognizing these misconceptions and offering practical solutions for them will promote effective nutritional care provided daily by all facility staff.

Principle #1: Clinical Nutrition Is More Than Section K of the MDS 

Although it is important for administrators and directors of nursing services to recognize Section K as the MDS section relating to oral/nutritional status, it is also vital to understand that nutrition is integrated throughout the overall RAI process. In fact, there are more than 60 MDS items that are guidelines or triggers that the clinical team should consider when completing the Resident Assessment Protocols (RAPS) for nutrition, dehydration/fluid maintenance or placement of feeding tubes. However...

Common misconception #1: "A comprehensive nutrition assessment includes information from Section K of the MDS only."

Solution: A comprehensive nutrition assessment should incorporate a review of all MDS triggers or guidelines related to a resident's nutritional status. Such an assessment considers the resident's "total picture," as presented by the MDS and, as such, facilitates creation of an accurate and complete resident care plan.

While there are many assessment forms and tools used by nutrition professionals across the nation, registered dietitians have desperately needed a comprehensive tool that supports the MDS format, incorporates best practices, permits accurate determination of nutritional risk and promotes effective time management for medical record documentation. As it happens, that tool is now available from Consultants for Long Term Care, Inc. (See Figure and "Guidelines Available").

Common misconception #2: "I don't have time to review all of the guidelines and RAPS related to nutrition."

Solution: Remember that a comprehensive nutritional assessment is not comprehensive if there are nutritional factors noted on the MDS but not considered in the overall assessment. Not considering these factors can result in untimely and inconsistent documentation, a need for recalculations or reassessment, a lower PPS reimbursement, and a lack of early identification and intervention, resulting in later, more costly nutritional intervention. Much of this involves additional--and wasted--time and increased costs.

Principle #2: Facility Systems and Processes Must Be Implemented by a Team to Achieve Successful Monitoring, Identification and Management of Nutritional Problems

Effective nutritional care depends on support from many programs, disciplines and departments. However...

Common misconception #1: The registered dietitian and dietary department are solely responsible for the nutritional care of the resident.

Solution: Recognize the need for interdisciplinary teamwork, taking into account the facility's:

* Hydration program

* Supplement program

* Weight program

* Dining program

* Skin care program

* Behavior management program

* Quality improvement program

Common misconception #2: The facility can use weight loss as the indicator for identifying and monitoring residents' nutritional risk.

Solution: While weight loss is one indicator that can be used for this purpose, there are many others. Key indicators for residents being nutritionally at risk include (but are not limited to):

* Unplanned weight loss or gain

* Presence of pressure ulcers/skin disorders

* Need for enteral feedings

* Presence of dehydration/inadequate fluid intake

* Abnormal lab values

In summary, nutrition is not just Section K of the MDS. Nutrition-related triggers and guidelines from the MDS should, in their entirety, be integrated into a comprehensive nutrition assessment. Key systems and processes that support effective identification and intervention must be included in the facility's quality improvement program.

Only in this comprehensive way can residents' nutritional needs be truly measured and met.

Brenda E. Richardson, MA, RD. CD. is nutritional care consultant for Consultants for Long Term Care, Inc.

References

(1.) Dempsey DT, Mullen JL Buzby GP. The link between nutritional Status and clinical Outcome: can nutritional intervention modify it? Am J Clin Nutr 1988;47(2 suppl):352-6.

(2.) Thomas DR, Ashmen W, Morley JE, Evans WJ. Nutritional management in long-term care: development of a clinical guideline. Council for Nutritional Strategies in Long-Term Care. J Gerontol A Biol Sci Med Sci 2000;55(12):M725-34.

RELATED ARTICLE: Guidelines Available

Professional associations continue to offer tools to support the prevention and management of malnutrition in the elderly. The Council for Nutritional Strategies in Long-Term Care has developed clinical guidelines, (2) and the American Medical Directors Association is in the process of publishing "Altered Nutrition Status Practice Guidelines" for the long-term care industry. Consultant Dietitians in Health Care Facilities, a dietetic practice group of the American Dietetic Association, offers new publications to assist providers in best practice standards and protocols for the nutritional care of residents. These include a revised "Pocket Resource for Nutrition Assessment," a revised "Dining Skills Manual" and "Nutrition Management and Restorative Dining for Older Adults."

A 10-month project by Consultants for Long Term Care, Inc., resulted in publication, in December 2001, of the "Nutrition Risk and Assessment Form" (complete with an instructional "how-to" guide for using the form). This tool integrates the RAI process, nutritional best practice standards from professional organizations, risk categories and survey requirements into one document. Each section incorporates nutrition-related items that correspond to those addressed in the RAI process and MDS 2.0. There is also a "Crosswalk Key" printed in yellow to be used as a quick reference in identifying specific MDS items that are nutritional guidelines or triggers for writing RAP summaries. These are identified on the form by a plate symbol and include: RAP triggered items #12: Nutritional Status; #13: Feeding Tubes; #14: Dehydration; and #16: Pressure Ulcers, as well as Centers for Medicare and Medicaid Services Quality Indicators #13: Prevalence of Weight Loss; #14: Prevalence of Tube Feeding; #15: Prevalence of Dehydrati on; and #24: Prevalence of Pressure Ulcers. Other items identified with a plate symbol are related to best practice considerations. Nutrition Risk categories are then determined based on the total number of plate symbol items selected: A summary section on the form is provided for documentation 6f appropriate interventions and strategies for these residents.

Using a single and comprehensive tool such as the "Nutrition Risk and I Assessment Form" will maximize time management. In field tests, registered dietitians initially completed the form in an average of 60 to 75 minutes. After using it a few times, the average time spent dropped to only 45 minutes per resident.