Promoting nutrition.

University of California-San Francisco nursing professor Jeanie Kayser-Jones, PhD, is a devoted daughter and researcher who studies nursing home nutrition and eating problems. But her expertise couldn't save her mother from choking to death while being fed on a special care unit.

Kayser-Jones requested thickened liquids and small portions. She shared her research and showed how eagerly her mother ate when fed slowly. In her absence, her mother aspirated food, was suctioned once, and laid flat in bed--where she died five minutes later.

"Forty to 50 percent of residents have swallowing disorders, and may require two or three minutes to move food to the back of their mouths. But because of inadequate staffing, they rush feedings, forcing huge spoonfuls that residents can't swallow," says Kayser-Jones, recounting both her research and her mother's death. "It's heartbreaking. Nursing home nutrition is a national problem. They've stepped back. It's like 30 years ago."

Many experts and industry insiders across the country concur. So do patient advocates, legislators, HCFA, and surveyors. They're looking hard, and promising harsh actions, including citations and civil monetary penalties, if facilities fail to serve residents' dietary needs.

Reduced reimbursement, staffing shortages, and high-acuity patients have soured some facilities on the gourmet menus once used to gain market share, but many are finding new ways to improve nutrition. And they're discovering that what was once a nursing or dietary issue is now a facility-wide concern.

While HCFA's new protocols, based on good practice, aren't new concepts, they represent a significant shift. The agency now expects the nursing department, rather than dietary, to get food into residents, notes consultant Annette Kobriger, RD, of Chilton, Wisconsin. The protocols also place the spotlight on a potentially weak spot in many long term care organizations. "National data says that every major problem identified in long term care is based on nutrition. If you don't pay more attention to nutrition, you won't fix your problems," says Nancy Wellman, PhD, RD, director of the National Policy and Resource Center on Nutrition and Aging at Florida International University. "Facilities always see dietary departments as a way to cut costs, It's more cost-effective to offer choices and to pay an RD for more hours to prevent problems. It's an investment in quality of care."

The right staff

To promote good nutrition, providers should first consider staffing. Eight hours of monthly consultation won't cut it, says Wellman, since it's spent on paperwork, with little time for staff training or patient assessment. As a general guideline, facilities need an RD at least halftime per 100 beds.

Other specialists can also pay off in better nutrition. Dentists evaluate and treat oral impediments and sensitivities. Speech pathologists assess swallowing difficulties and train staff on proper feeding and positioning.

"Pharmacists are often forgotten, but can offer adjustments in formulation and equipment that help ease tube feedings, TPN and PPN, for patients and staff," says pharmacist Ray Martin, director of accreditation for Omnicare, a Covington, Kentucky-based national provider for pharmaceutical care and clinical consultation. "They also assess the impact of medications on taste, weight gain and loss, and the need for vitamins and supplements."

The need for such specialists, however, shouldn't diminish the important role played by CNAs. With training, these frontline players are in a position to improve care dramatically. But despite high expectations, nursing assistants may have just an hour of training on feeding techniques. They may also lack supervision if nurses use mealtimes for paperwork or med passes.

To ease the burden on CNAs, who can legally feed residents, more and more facilities are recruiting and preparing other staff to pass trays, cut food, and cue diners. Three years ago, when Colony Oaks Care Center, a 102-bed intermediate and skilled nursing facility in Appleton, Wisconsin, couldn't recruit enough nursing assistants, it took their unfilled hours from nursing and created new positions. Today, 10 dining assistants, dressed in burgundy tops to coordinate with the dining room, feed residents, pass nourishments and water, document intake, and assist with restorative nursing and ambulation. "It's easy to hire them and put them through our CNA class," says dietary manager Shirley Vetter.

Family members like the program because residents get extra attention, and weight loss has been reduced from over 3 percent to less than 2 percent--while saving more than $500 annually on supplements.

Another facility is going even further to augment staff and create a companionable environment. At St. Patrick's Residence, a 210-bed sheltered, intermediate, and skilled care facility operated by the Carmelite Sisters for the Aged and Infirm in Naperville, Illinois, managers recruit and train volunteers aged 17 to their late 70s for the facility's "Company for Dinner" program.

"What makes it marketable is you don't have to feed," says development director Laura Weren. "If you're best at being lively, keep conversations going and encourage residents to feed themselves." Forty volunteers cover all meals, using four-legged stools to circulate easily.

Special name tags for volunteers tell staff who's trained to feed. A computer printout on trays lists information on each resident's dietary needs, abilities, and swallowing problems. If a resident needs encouragement to eat more, the dietary department places red place mats on his tray, a subtle, dignified way to communicate the need. Nursing assistants document patient intakes.

For staff with limited patient contact, participation is a rewarding reminder of their mission. The housekeeping manager at St. Patrick's had the department trained and requires them to pass breakfast trays. "It's helped departments work better together," says Weren. "You know them better when you work beside them and share conversations." In addition to less plate waste and less weight loss, timely tray returns give more time to prepare subsequent meals, and residents finish sooner, giving them longer breaks between meals.

What not to do

In the staffing equation, good supervision and ongoing training are essential. Inadequate oversight permits a numerous problems to flourish. Poor positioning can cause aspiration and subsequent pneumonia. Residents go hungry while staff deliver and remove trays that remain virtually untouched because residents weren't awake, or able to reach, open, or eat items without assistance.

Other problems are more shocking. Workers, who may be pressured to ensure that residents consume 75 percent of their meals, have been caught flushing food down toilets, or eating it themselves. Other staff, and visitors, eat resident meals because of financial pressures, mealtime hunger, or desire for particular items. Kayser-Jones and ombudsmen say they suspect food theft occurs far more frequently than most managers realize, justified by staff who resent low salaries or working through meals. Offering employees the same meals at a reduced rate can serve both the residents and employees.

At the root of many common mistakes is a belief that eating is merely a matter of nutrients. Keep in mind that the dining experience has a tremendous effect not only on residents' nutritional status and overall satisfaction, experts say. Since food symbolizes love and concern, serving poor food, or serving it poorly, tells customers that facilities don't care.

Kobriger has calculated that residents spend 50 percent of their waking time in dining rooms. "Sometimes the only kind of humanness, self-expression, and social interaction happens there, but some facilities have completely dehumanized dining into a factory product line where they just throw the food down," she says. "The only thing residents hear while eating is 'Pick up your fork."' Solitary meals in resident rooms also depress appetites.

Special problems occur with residents with dementia and others needing assistance with feeding, particularly pureed diets. Experts say pureed diets are overused; in many cases, chopped foods will suffice. When purees are used, be sure staff know and convey the identity of food.

Other common practices can also be a drain on nutrition and quality of care. Some time-pressured staff mix items, or the entire meal, into one revolting mound, moisten it with beverages, and force feed huge spoonfuls. Others hold glasses against residents' mouths, forcing them to chug down purees stirred into supplements. Residents who resist or turn away-either repulsed by the food, or to swallow what's in their mouths-are considered belligerent or uncooperative by staff and treated accordingly.

Other experts warn about "fixing" dietary problems by adding supplements to the mix. "Supplements destroy appetites," Kayser-Jones says flatly. "They medicalize care." Furthermore, supplements are often left unopened, or languish so long at nurses' stations and resident rooms that they become unpalatable or unsafe.

What they want

Improving residents' nutritional status may take putting yourself at their table. "Imagine never having a choice of food for the rest of your life," says Kayser-Jones. "Even if you don't like selective menu foods, you still get to choose." Her 1981 cross-cultural nursing home comparison found that Scottish facilities offered three entrees and three desserts; now they offer four. Tasty, blended fresh fruit smoothies provide fiber and prevent constipation; residents even get fresh-squeezed orange juice-better food than they may have served at home.

Few facilities provide ethnic meals that meet resident needs. "Forty percent in our study were Asian, and they didn't even get tea," reports Kayser-Jones. "Facilities say ethnic foods are too expensive, but unless residents are acculturated, they won't eat much [non-ethnic] food. Why not provide rice instead of spaghetti?"

Imagine a multi-ethnic restaurant menu and you've pictured the substitution list at Warren Barr Pavilion, a 294-bed Chicago SNF. "We can do ethnic with a half-hour's notice, even during meals," says food and nutritional service director Janice Mahon. The list includes frozen kosher potato pancakes and stuffed cabbage, German foods, fried shrimp, steak, salmon, bratwurst, rice and beans, and vegan meals.

When a terminally ill client who refused tube feedings and regular meals requested citrus pies, Mahon satisfied her with nutritionally supplemented lemon meringue and lime cream pies, offered with each standard meal. An Asian man ate baked fish daily for breakfast.

Other innovations include assigning staff to unit teams rather than to departments, cross-training dietary staff as cooks, table-side dessert carts, and the optional Oak Room Buffet, offering residents, staff and visitors three entrees, salad bar, dessert bar, and other selections. The employee cafeteria serves the same meals, including drink and dessert, for about $2.

Corporate menus should include regional taste variations, cautions Eileen Hisel, RD, of Health Technologies, dietary consulting firm in Maryland Heights, Missouri, citing a Louisiana company that mandated gumbo in Illinois. "Facilities didn't even recognize some ingredients, and small farming communities don't want lobster bisque and seafood," she says.

An experimental multi-entree buffet meal service proved so successful that Johns Hopkins Geriatrics Center, a 240-bed comprehensive facility in Baltimore, Maryland, is expanding it to all three meals. Residents, who could try a little of everything, request seconds, or eat in courses, consumed more calories and food, reports long term care research director Robin Remsburg, PhD, RN. "We served only what residents wanted," she says. "They're disturbed by waste."

They also don't want to bother the staff. "I don't feel guilty about asking for help," says Frank Suttel, 86, a double amputee and former five-and-dime store owner. But although he enjoyed evening snacks, he never requested one at Schofield Residence, a 120-bed intermediate and skilled nursing facility in Kenmore, New York. "If I wanted something, the nurses would be happy to get it. Most that would ask didn't eat the regular meal. Nursing homes operate on a cost basis, and food has to stay in line with costs."

Since Schofield implemented a "hospitality cart" that delivers cookies, ice cream, fruit, shakes, juices, sandwiches, coffee, custards, Popsicles, cocoa and other items--all previously available on request--Suttell anticipates and enjoys nightly snacks. "It's a nice fill-in," he says.

Several fragile Schofield residents still receive nutritional supplements, but since starting the snack cart a year ago, Schofield has been able to discontinue nearly all scheduled nourishments. "When they can choose, they tend to eat more or all of their meals," reports Jane Brenon, a registered dietitian at the facility. "Our study found that 40 percent gained approximately three to six pounds, while the majority remained stable."

Recipe for savings

Trimming food and related staffing expenditures will yield further spending, not savings, say Kobriger and others.

long term care providers that cut foodservice budgets to save money can double their food costs if they end up providing supplements, notes Kobriger. And besides paying for supplements, they incur additional hours for professional nursing and for nursing assistants or dietary aides, since supplements require additional fluids to prevent dehydration. Accounting firms have calculated each nursing med pass costs $1 to $2. Giving nutritional shakes requires 10 minutes minimum.

"Preventing malnutrition is the best way facilities can save money," says Kobriger. "Weight loss will cost more than food."

Malnutrition's impact on resident health goes beyond obvious problems, such as pressure ulcers, to increased infections from depressed immune systems, reduced stamina for therapy and activities of daily living, impaired mobility, depression, organ damage, and behavioral changes, she says.

Add to that the impact of HCFA's new survey protocols and focus on fraud. Providers can face substantial survey citations and monetary penalties, particularly if other states follow Pennsylvania, which recently charged facilities for Medicare fraud, arguing that malnutrition is a failure to provide services included on MDS checklists.

Some dietary departments even generate revenue by serving day care centers and providing on-site community Title V meals. And even when residents are too confused to express appreciation of good dietary programs, they're still effective family-pleasers and marketing incentives.

As Kobriger says, good food still gives facilities an edge.

"Mealtime should be the main event of the day, so make it special," agrees Kayser-Jones. "All residents would eat better if they looked forward to meals. Residents feel better fully dressed and eating in the dining room. Even milk tastes better."

The task of improving the quality of care as it relates to nutrition may not be easy, but it's possible if providers stress teamwork. "The new protocols raise the bar and expectations a few notches," says manager and registered dietitian Hisel of Health Technologies. "Facilities need to share the quality indicators with all department managers. It's all interdisciplinary."

Wendy L. Bonifazi is a contributing writer to Contemporary Long Term Care.

Practice pointers

Consider these tips to Improve care and fare better at survey time.

* Arm caregivers with Nutrition Care Alerts, training aids created recently by a coalition of government and health care groups including the American Dietetic Association. Investigative protocols listed in the survey procedures may also be helpful; they are designed to help caregivers identify and address nutritional problems.

* Provide related in-services for new hires and refreshers at least quarterly, covering dysphagia, positioning, and other issues.

* Surveyors now head straight to kitchens on all shifts, looking at cleanliness, sanitation, and safe food handling including thawing, cooling, and heating times and temperatures. Hazard Analysis of Critical Control Points (HACCP) manuals provide good guidelines.

* Don't save charting for care planning. Instead, do more incidental and interim charting of concerns, conversations, and actions. "Better documentation of your rationale can go a long way at survey," says Hisel, particularly when nutritional needs are contradictory.

* Clarify and update advance directives with residents and families, documenting whether or not they consider tube feedings regular nutrition. "They may not have the same opinions now as 10 years ago," says Hisel. And to prevent citations, document the advance directives, noting that dehydration is expected and is not noncompliant.

* Prevent sanitation problems with a cleaning schedule and daily QA spot checks for cleaning, labeling, and dating in all facility kitchens.