Indiana Healthcare Leadership Conference March 31, 2011 Regulation & Survey Process Related to Nutrition & Hydration Brenda Buroker, RN, ISDH Survey Manager Donna Downs, RN, ISDH Area.
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Transcript Indiana Healthcare Leadership Conference March 31, 2011 Regulation & Survey Process Related to Nutrition & Hydration Brenda Buroker, RN, ISDH Survey Manager Donna Downs, RN, ISDH Area.
Indiana Healthcare
Leadership Conference
March 31, 2011
Regulation & Survey Process Related
to
Nutrition & Hydration
Brenda Buroker, RN, ISDH Survey Manager
Donna Downs, RN, ISDH Area Supervisor
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.
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.
ASSESSMENT
General Appearance
Height
Weight
Current Standard of Practice for Weighing
Admission /Readmission
Weekly for first 4 weeks
Monthly
Significant Change in Condition
ASSESSMENT
Food and Fluid intake
• Chewing abnormalities
Altered Nutrient intake
• Swallowing abnormalities
Inability to consume
meals provided
Insufficient availability
of food
Environmental factors
Medications
Disease or condition
• Functional ability
• Medications
• Goals and prognosis
• Laboratory Test
Serum Albumin
Pre-albumin
ANALYSIS & EVALUATION
RAI Information
Information from assessment
Review / Analyze information
Identify or determine status
Risk for unplanned weight loss
Able to maintain acceptable parameters
WEIGHT LOSS PARAMETERS
INTERVAL
1 month
SIGNIFICANT
5%
SEVERE
>5%
3 months
7.5%
>7.5%
6 months
10%
>10%
CARE PLANNING &
INTERVENTIONS
Resident Choice
Functional Factors
Meet Nutritional Needs
Chewing & Swallowing
Diet Liberalization
Medications
Weight – Related
Food Fortification &
Interventions
Weight Gain
Environmental Factors
Anorexia
Wound Healing
Supplementation
Fluid & Electrolyte
Appetite Stimulants
Feeding Tubes
End-of-Life
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
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
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
INVESTIGATIVE PROTOCOL
INTERVIEW
RESIDENT, FAMILY OR REPRESENTATIVE
Necessary equipment
Preferences
Choices / Substitutions
Supplements / Snacks
Refusal of therapeutic approaches explained
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
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
INVESTIGATIVE PROTOCOL
Assessment & monitoring
Care Plan
Care Plan Revision
Facility Practices
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
INVESTIGATIVE PROTOCOL
POTENTIAL ASSOCIATED TAGS
F150 – Resident Rights
F329 –Unnecessary Drugs
F272 – Comprehensive
F353 – Sufficient Staff
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
F361 – Dietary Services
F362 – Standard Sufficient
Staff
F385 – Physician Services
F500 – Use of Outside
Resources
F501 – Medical Director
F522 – Quality Assessment &
Assurance
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.
RISK FACTORS
Coma /decreased sensorium
Fluid loss and increased fluid need
Fluid restriction (renal)
Functional impairments
Dementia
Refusal of fluids
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
PROBES
• Clinical signs of insufficient fluids observed
• Laboratory results – abnormal
• Facility actions
• Identify risk factors
• Care provided
• Alternative treatment
QUALITY
INDICATOR
SURVEY
(QIS)
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)?
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?
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.
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
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
QIS
ASE-Q calculates the requested dates and percentage of
weight loss.
Critical Elements Pathway
Nutrition -- none
Hydration -- yes
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.
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.
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.
KEY POINTS – Traditional & QIS
DOCUMENTATION:
Assessment
Care Plan
Interventions
Implementation
Individual Needs – identified and addressed
Plan/Interventions are successful
Revisions if necessary
THANK
YOU