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Improving the Nutritional Care of Nursing Home Residents.

An investigator finds nursing homes tailing short of this key quality indicator

Mealtime problems in nursing homes are widespread, interdisciplinary and serious. Feeding or assisting residents at mealtime is one of the most time-consuming, but also one of the most important, aspects of care. If residents are not fed adequately, they will become malnourished and dehydrated.

Malnutrition is a common, potentially serious, frequently undetected, yet often avoidable problem in nursing homes. Studies have shown that 35 to 85% of nursing home residents are malnourished, despite state and federal regulations designed to ensure adequate nutrition. [1] There has been very little research on the prevalence of dehydration, although in our study, we found that only 1/40 residents received an adequate amount of fluids. [2]

When nursing home residents do not receive adequate nutrition and fluids, they are more susceptible to urinary tract infections, pneumonia, pressure ulcers and confusion. Furthermore, if residents become dehydrated, serious life-threatening electrolyte imbalances (e.g., hypernatremia [high levels of sodium] and hypernatremia [high levels of potassium]) can occur. If residents become seriously dehydrated, their kidneys will cease to function, and they will die.

In our study, we found that these problems might sometimes be worse than they appear in residents' medical records. We found, for example, that the percentage of food eaten by nursing home residents, as recorded by the nursing home staff, is often erroneous. The certified nursing assistants (CNAs) consistently estimated that the residents ate a higher percentage of food than was actually eaten. [3]

We also found that when residents lost 5% of their weight in one month, typically, the staff called the physician and obtained an order for a commercial supplement. When we did a three-day dietary analysis of 40 of the 100 residents in our study, commercial supplements had been prescribed for 29 of them. Only 9 of the 29 residents were served the correct number and type of supplements as ordered, and only 2 consumed the full amount of supplement as prescribed by their physicians. [4] This is problematic because, on the resident's record, it appears that the weight loss problem has been addressed, but when residents do not take the supplements, some of them will continue to lose weight and die from malnutrition.

We found several reasons why residents became malnourished and dehydrated. First, there were not enough staff to feed and assist residents at mealtime. Many people in nursing homes are physically and cognitively impaired, and they need partial or complete assistance with their meals. On the day shift (7 a.m. to 3:30 p.m.), the staffing was fairly adequate, but in the evenings (3 to 11 p.m.), each CNA typically had 8 to 15 residents to feed or assist at mealtime. One CNA cannot possibly feed/assist 8 to 15 residents adequately. Sometimes the trays were taken into the room, but no one helped the resident eat. The untouched trays were eventually taken away, leaving the resident unfed. In some instances, because the CNAs were overburdened, they spent only a few minutes feeding the residents.

It is important for CNAs to be supervised by the licensed staff, but there was little supervision of the CNAs we studied. In the evening, one licensed nurse (an RN or an LVN) was often responsible for the care of 35 to 45 residents. The licensed staff were so busy passing medications, admitting new residents and doing treatments that they did not have time to oversee the care provided by the CNAs. Thus, the CNAs determined the residents' nutritional intake.

While some nursing homes are working diligently to serve food that is tasty and attractive, we found that many residents were served pureed food. The kitchen staff pureed the food that was being served on the regular menu. They served, for example, pureed spaghetti, bread, cookies, cake, waffles, etc. When these foods are pureed, they are unidentifiable and unappetizing. Many residents refused to eat them.

Although dysphagia (impaired swallowing) evaluations are now being performed more often, during our study we found that while 45 of 82 residents (55%) had some degree of dysphagia, only 10 of these 45 (22%) had been referred to a speech pathologist for an evaluation. [5] Sometimes the CNAs did not know that a resident had a swallowing disorder and fed the residents too rapidly. The residents coughed and choked, indicating that they were aspirating food and liquids.

Swallowing disorders were further complicated by many residents' poor oral health. About half of the 100 residents in our study had no or few teeth and no dentures or poorly fitting dentures. Only 3 residents had dentures that fit properly. Because many of the residents had lost weight, their dentures were loose. Some residents literally tried to hold their dentures in their mouths with one hand while eating with the other. When people do not have teeth or dentures, it is sometimes difficult for them to drink enough liquids. Without teeth, they cannot close their mouths tightly and as they attempt to drink, the liquids spill out of their mouths.

In general, the residents most at risk for malnutrition and dehydration are those who are physically and cognitively impaired, have swallowing disorders and poor oral health, are unable to speak English and do not have family members who can assist them at mealtime. Elderly residents who have immigrated to the United States from another country are in double or triple jeopardy. Often they cannot speak English and cannot make their needs known. Further, they are usually served Western food, which they might never have eaten before. We observed, for example, that while some Chinese residents were somewhat "Americanized" and ate Western food, others often ate little of the food that was served.

There are several recommendations I would offer when a resident is not eating well. First, there should be an interdisciplinary assessment of the problem involving the physician, the licensed nurse, the CNA, the dietitian, the pharmacist, and the speech and occupational therapists. Ideally, a gerontological clinical nurse specialist (GCNS) or a gerontological nurse practitioner (GNP) is the professional who can bring this team together because he or she offers a depth and breadth of knowledge concerning the care of older people. These nurses, specially trained in gerontological nursing, understand the physiology and pathophysiology of aging, and they have knowledge of the pharmacological, social, cultural and psychological problems that might influence nutritional intake.

Secondly, the CNAs need and would probably appreciate supervision from the professional staff. They need frequent in-service education programs on how to care for residents who are not eating well. They need, for example, to learn that residents with swallowing disorders must be fed slowly and carefully, and that it is very important to position residents properly at mealtime (see Kayser-Jones & Pengilly [5] for information on signs and symptoms of swallowing disorders and interventions to facilitate feeding residents safely).

Most nursing homes offer residents some choice of food, but we need to increase our efforts in this regard. Food likes and dislikes are highly individualized. When I did research in Scotland 22 years ago, the residents (who were very homogenous) had a choice of three entrees and three desserts for their midday and evening meals. This choice of food was highly valued by the residents. [6,7] Some nursing home administrators have told me that it is not economically possible to have a selective menu. We found, however, that a large amount of food is being discarded at mealtime. If residents had more choice, there would be less food waste.

Whenever possible, residents should be out of bed and in the dining room at mealtime; many residents in our study were observed eating their meals in bed. One resident said: "Beds are for sleeping, not for eating." Some residents stated that they weren't hungry because they remained in bed all day.

The dining environment is very important. Many facilities offer a beautiful candlelight dinner once a month, and the residents enjoy this special event. In one facility, the dietary staff and the social worker made a great effort to transfer 10 to 15 residents to the dining room every day for lunch. The dining room was beautiful, and the residents were served as they would be in a nice restaurant. The social worker remarked that the residents ate better when they ate in the dining room. "Everything tastes better," she said. "The bread tastes better. The milk tastes better. The residents feel special."

Food is one of the few remaining pleasures for many nursing home residents. Many can no longer walk; day after day they remain in the nursing home, deprived of fresh air and sunshine. If their vision is poor, they can no longer read or see the beauty of nature. If they are hearing-impaired, they cannot hear music or the voices of their loved ones. Food is so important--physiologically, psychologically, socially, culturally and symbolically. When residents are served food that they do not like or cannot eat, it conveys the impression that we do not value them. Every mealtime should be a special event for the resident--the main event of the day.

Nutrition is just one part of a resident's care, but in some ways it is the most important part. If we do not provide food and water to residents in their last days of life, if we allow them to become malnourished and dehydrated, then what point is there in giving them medications, physical therapy or other treatments? On the other hand, if we can work together to improve the nutritional care of residents, malnutrition and dehydration can become things of the past. Nursing facilities will take pride in their efforts, and residents and their families will feel valued and more satisfied with their care.

Jeanie Kayser-Jones, RN, PhD, FAAN, is Professor, University of California, San Francisco, School of Medicine, Department of Physiological Nursing, School of Nursing & Medical Anthropology Program. For further information, write Dr. Kayser-Jones at the University of California, San Francisco, School of Nursing, Box 0610, San Francisco, CA 94143-0610.


(1.) Morley JE, Silver A. Nutritional issues in nursing home care. Annals of Internal Medicine 1995; 12(2):850-9.

(2.) Kayser-Jones J, Schell ES, Porter C, Barbaccia JP, Shaw H. Factors contributing to dehydration among nursing home residents: staffing and lack of professional supervision. Journal of the American Geriatrics Society 1999; 47(10):1 187-94.

(3.) Kayser-Jones J, Schell E, Porter C, Paul S. Reliability of percentage figures used to record the dietary intake of nursing home residents. Nursing Home Medicine 1997;5(3)69-76.

(4.) Kayser-Jones J, Schell E, Porter C, Barbaccia JC, Steinbach C, Bird WF, Redford, Pengilly K. A prospective study of the use of liquid oral dietary supplements in nursing homes. Journal of the American Geriatrics Society 1998; 46(11):1378-86.

(5.) Kayser-Jones J, Pengilly K. Dysphagia among nursing home residents: Consequences and recommendations. Geriatric Nursing 1999; 20(2):77-82.

(6.) Kayser-Jones J. Old, Alone and Neglected: Care of the Aged in Scotland and the United States. Berkeley, CA: University of California Press, 1981.

(7.) Kayser-Jones J. Old, Alone and Neglected: Care of the Aged in the United States and Scotland. Berkeley, CA: University of California Press. Paperback edition, 1990.
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Publication:Nursing Homes
Geographic Code:1USA
Date:Oct 1, 2000
Previous Article:Reducing Medication Errors in Long-Term Care.

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