Weight loss prevention strategies: what is your facility's score? preventing unintended weight loss in residents requires a multidisciplinary approach. (Feature Article).

Preventing weight loss and malnutrition--and the occurrence of pressure ulcers that these can contribute to--is a hot topic for long-term care facilities. As a result, survey citations, civil lawsuits, and Medicare fraud prosecutions related to nutrition have become routine risk-management issues. Facilities across the country, however, have implemented successful strategies for managing nutrition, and we have incorporated their "best practices" into a scorecard (Figure). Although this scorecard has not been scientifically tested, facilities might find it useful in assessing and improving their nutritional programs, as well as giving them new ideas.

Managing nutrition requires a multidisciplinary approach, involving administration, the rehab/therapy-departments, the nutrition professional, nursing, and the medical director. This article will highlight some of the nutritional best practices as they relate to each of these key players on the facility "nutrition team."

"Nutrition Team" Members' Roles

Administration. The facility administrator has an important leadership role in the caregiver team. By being present in the dining room at least once weekly, he or she demonstrates to other staff members that mealtime is an important activity. Regular visits by the administrator also have a positive effect on resident satisfaction and families' initial impressions when touring the facility.

In addition, these routine visits are important because the dining room is one of a facility's major cost centers. The hours spent there by certified nursing assistants (CNAs) alone, especially on the day shift, represent a significant cost. Add to that the wages of the dietary staff, costs of food, and supplement expenses, and it becomes obvious that the dining room deserves and requires the administrator's attention.

The administrator must make it a point to know who's in charge of the dining room. This would seem obvious, but although in some facilities it is supervised by the dietary director and in others by the assistant director of nursing, the dining room often has no particular staff person in charge. For all practical purposes, this means that the employees working there determine the rules-- certainly not an advisable way for a business to operate one of its major cost centers. Each facility needs to decide who would be the best person to oversee its dining room, but someone definitely should be in charge.

One method to help administration stay on top of important issues in the dining room is to use a checklist that includes issues surveyors look for there. Daily checking ensures that potential or existing problems are addressed in a timely manner. Issues to consider in the dining room are:

* availability of adaptive equipment;

* correct diets for residents;

* correct food/fluid textures; and

* availability of substitutes for residents not eating planned menu items.

Using a checklist and having a specific person in charge of the dining room will help ensure that dining needs--such as food dislikes, a decline in a resident's ability to feed him/herself, or behavior problems--are being communicated to the appropriate staff member who can help.

Rehab/therapy departments. A rehabilitation dining program is an important resource for residents with declining self-feeding skills. By being present regularly in the dining room, occupational-and speech-therapy staff can screen for eating, swallowing, and positioning difficulties. This can help maintain and prevent declines in residents' ability to feed themselves. In addition to maintaining the best quality of life possible for residents, identifying their needs in these areas can lead to additional Medicare Part B therapy referrals, as well.

Nutrition professionals. The registered dietitian, who generally serves the facility on a consultant basis, and the facility's dietary department form a vital component of the team that oversees nutrition. The administrator usually decides how many hours each week the facility needs a consultant dietitian. A minimum of eight hours weekly for every 100 residents is generally recommended. Allowing adequate time for consultation is essential to positive outcomes. It is also recommended that the consultant dietitian communicate with both the DON and the food-service director during each consultation visit. It should go without saying that to benefit from the consultant dietitian's recommendations, the facility must implement them.

The dietary department plays a critical role in meeting residents' needs for food and fluids. The dietary staff needs to make critical information regarding residents' nutritional needs and problems available to the consultant dietitian.

One area of concern for nutrition professionals is residents' end-of-life wishes regarding nutrition and hydration. When residents are first admitted, it is important to determine whether they have completed advance directives regarding these issues, which specify the nutritional support they want or don't want to receive if they later become unable to make their own medical decisions. Determining this at admission provides an opportunity for the resident and family to discuss the resident's future wishes if advanced directives have not already been completed prior to admission. Making the best decisions for residents regarding such weighty matters requires presence of mind; therefore, the best time to discuss them is at admission, not after the resident already has begun to lose weight or has trouble eating.

Nursing. The dining room is where the responsibility for residents' nutrition shifts to nursing staff This is where the nutrition care plan is implemented. Feeding is generally designated as a nursing responsibility. In the past, only licensed professional staff were permitted to feed, and most feeding and assistance to residents was the responsibility of CNAs. However, this spring the Centers for Medicare and Medicaid Services approved the use of feeding assistants in the dining room.

A licensed nurse has typically been present in the dining room to pass medications, but he or she obviously cannot monitor the dining room at the same time. Often this means that there is no one to make sure the nutrition care plan is implemented in the dining room. This gap needs to be filled.

A licensed nurse in the dining room should ensure that:

1. Residents are participating in the walk-to-dine program.

2. Residents transfer from a wheelchair to a regular chair for dining.

3. Therapeutic diets and texture-altered foods and beverages are served correctly.

4. Residents are positioned properly and table height is correct.

5. Food is served properly and in the proper sequence.

6. Needed positioning aids and adaptive equipment are present.

7. Swallowing precautions are taken and that other special resident needs for dining are met.

8. Recording of food and fluid intake is accurate.

9. Residents are fed with dignity.

10. Substitutes are offered.

Physician (medical director). When residents experience a weight loss, the medical director must be notified, because lack of food intake and weight loss frequently are caused by a new or worsening disease process, and changes in residents' health status require the intervention of a physician. The medical director also participates in the development of facility protocols and is the most likely person to communicate with residents' attending physicians.

Residents at Risk

The teamwork of the professionals mentioned in this article also extends to assessing which residents are at risk for nutritional problems. A multidisciplinary "nutrition-at-risk" committee--typically consisting of the DON or assistant DON, dietary director, nursing representative(s) and skin-care nurses, administration, therapies, and social service representatives--usually meets weekly to discuss the nutritional needs of residents, between quarterly care conferences. The weekly meetings are needed because residents' status can change quickly with the development of a new illness, fever, deteriorated eating ability, or swallowing difficulties. These weekly meetings can be quite effective in preventing weight loss. After the committee's initial meetings, most facility staff say that these weekly meetings last only about 20 minutes--a small commitment of time for such a large potential benefit.

Residents who have been determined to be at nutritional risk must be tracked so they do not fall between the cracks. This tracking should be carried out at least monthly, to allow staff to stay up to speed as to whether current interventions are working.

Items frequently tracked are food and fluid intake, abnormal laboratory values, and the occurrence of pressure sores. It is recommended that the dietitian document the following monthly: weight changes, poor food intake, abnormal laboratory values, pressure-sore changes, and changes in activities of daily living or cognitive status.

Accurate food-intake records are necessary for guiding the selection of nutritional interventions. Recent studies show, however, that food intake is usually overestimated by 20%; such inaccurate information makes care planning difficult and must be improved. Supplements have been described by the Institute of Medicine as the "fast food of the long-term care industry." Nevertheless, supplement intake also needs to be accurately documented.

Tube-Feeding Policy

Despite multiple interventions aimed at preventing weight loss and dehydration, there will always be some residents who will stop taking in adequate calories and! or fluids. Some of these residents will need/want a tube feeding, so it is important that each facility have a tube-feeding policy and procedures in place. The policy should designate at what point tube feeding (or intravenous therapy) should be implemented, if at all, depending on residents' previously documented wishes.

If the resident does not have advance directives regarding nutrition and hydration, the decision must be made at this point whether to implement nutrition and/or hydration support, or to simply offer comfort measures, which usually means that food and fluids will be provided to residents as long as they will, or can, accept them. However, facilities should have alternative interventions in place that can be tried before initiating tube feeding.

One such intervention involves the use of "liberalized diets." Liberalized diets provide the opportunity for residents to eat "like they are at home." The American Medical Directors Association's Clinical Practice Guideline for Altered Nutritional Status state the following: "Routine dietary restrictions are usually unnecessary and can be counterproductive in the long-term care setting. Special diets for diabetes, hypertension and heart failure, and hypercholesterolemia have not been found to improve control or affect symptoms." The one exception is protein restriction in late-stage renal insufficiency, before dialysis.

Liberalized diets have other benefits, such as improved resident satisfaction and outcomes. Money is saved, also, when fewer special dietary purchases and substitutions are made. Survey outcomes are improved by less weight loss and less resident dissatisfaction.

Another approach is a fortified food program, which uses favorite foods to increase residents' intake of calories, protein, and fat. A favorite food in a fortified food program is "super cereal"--hot cereal fortified with nonfat dry milk, sugar, and butter. This combination increases the calorie content of hot cereal by four to five times. The resident does not have to eat a huge amount of food to get sufficient calories, so this concentrated calorie program also reduces time spent by staff feeding residents.

The Team's Goal

This article has provided a facility scorecard to determine whether best practices to prevent unintended weight loss, dehydration and pressure sores are being followed. Everyone involved in resident nutrition should share the goal of having a rate of unintended weight loss in their facility of less than 3% of the entire population. The healthcare team members all play a vital role in making sure that goal is reached.

Figure. Score 5 points for each "True" box marked. 85 points or
more--Excellent 70-85 points--Very good, 55-70 points--Good, fewer than
55--work Needed. This scorecard has been provided to determine your
facility score in nutrition best practices. The scorecard is a guide to
use to improve resident outcomes at your facility.

FACILITY-WIDE SCORECARD

                                                          True  False

ADMINISTRATION:

 1. Administrator present in dining room at least
    weekly.
 2. Someone is designated as "being in charge of the
    dining room at all meals."
 3. Routine tool for monitoring dining room is in place.
 4. Plan for observations in the dining room to be
    routed to correct discipline is in place.

THERAPIES:

 5. Rehabilitation dining program is in place.
 6. Therapies (Occupational, Speech) are in our dining
    rooms on a regular basis.

NUTRITION PROFESSIONAL:

 7. RD * is available at least eight hours per week for
    each 100 residents.
 8. RD's recommendations followed through.
 9. Advance directives for nutrition/hydration done at
    admission.
10. Our facility has a policy and procedure in place to
    designate when a resident is evaluated for a tube
    feeding.
11. Liberalized diets available.
12. Our facility has a fortified-foods program in place.
13. Our facility has a "nutrition-at-risk" committee
    that meets regularly.
14. Our facility tracks residents at nutrition risk.

NURSING:

15. Food/fluid intake has been monitored and is
    adequate.
16. System for tracking supplement intake.
17. Licensed nursing presence in dining room daily.

PHYSICIAN:

18. MD is routinely notified of decrease in appetite.
19. MD participates in development of care protocols.

ALL:

20. Our unintended weight loss is less than 3%.

* RD = registered dietitian

Kobriger Presents, Inc. [c]2002

Suggested Reading

American Medical Directors Association (AMDA). Clinical Practice Guideline: Altered Nutritional Status. Columbia, Md,: AMDA, 2001.

Dunn H. Hard Choices for Loving People--CPR, Artificial Feeding, Comfort Care and the Patient with a Life-Threatening Illness. Herndon, Va,: A & A Publishers, Inc.; www.hardchoices.com.

Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 1999;282:1365-70.

Hoffman DR. The False Claims Act as a remedy to the inadequate provision of nutrition and wound care to nursing home patients. Adv Wound Care 1996;9:25-9.

Kayser-Jones J, Schell E. The mealtime experience of a cognitively impaired elder: Ineffective and effective strategies. J Gerontol Nurs 1997;23:33-9.

Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med 1997;157:327-32.

Pokrywka HS, Koffler KH, Remsburg R, et al. Accuracy of patient care staff in estimating and documenting meal intake of nursing home residents. J Am Geriatr Soc 1997;45:1223-7.

Sheiman SL. Tube feeding the demented nursing home resident. J Am Geriatr Sco 1996;44:1268-70.

Annette M. Kobriger, RD, CD, MPH, MPA, is president of. Kobriger Presents, Inc., which provides seminars, publications, and consultation nationally for the long-term care industry. Contact her at [phone], email [e-mail], or visit www.kobriger.com to receive a complete catalog of CEU materials offered by Kobriger Presents, Inc. To comment on this article, please send e-mail to [e-mail].