In long term care, we get conditioned to speaking in acronyms. Let’s start breaking down our jargon, and start again. Every professional in long term care has a role in the care of the resident. As dietitians and dietary managers, we are interested in the nutritional aspect of resident care. The government created a tool for healthcare workers to assist in assessment. This tool is MDS, Minimum Data Set, or basic information needed to complete an assessment in each area of care. The Centers for Medicare and Medicaid Services (CMS) developed an education manual to assist in filling out the MDS sections, the most recent called MDS 3.0 RAI (Resident Assessment Instrument) Manual. Refer to this site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient…/MDS30RAIManual.html
The government desires the MDS to be completed in regular intervals depending on current level of care the resident is receiving at the facility. The facility’s MDS coordinator will set a due date for MDS and this is called the ARD or Assessment Reference Date and this is the date that signifies the end of the look back period. There is a 7 day time period before the ARD that is the observation period used to determine our answers to the MDS questions. Section K is the nutrition section and reviews swallowing, weight change, and diet orders. Since these items can change up until midnight of the Assessment Reference Date, section K is not to be completed until the day after the ARD date.
Section K starts with questions regarding swallowing. This may require a team approach, since swallowing issues can occur on any shift. A recommended approach is to observe a meal, plus interviewing dietary and nursing staff, and reviewing speech therapy notes if appropriate. If the resident is already on a texture modified diet, this does not automatically indicate swallowing issue. It only triggers if the resident has any tolerance issues on that particular mechanically altered diet in the 7 day observation period.
Height and weight should be easy facts to determine, however we still question these details frequently. Height is to be entered in inches. Review MDS 3.0 guidelines for alternative methods of determining height, such as knee height, or arm span. Residents are to be re-measured for height every year. For example, a resident becomes a bilateral amputee, requiring re-measurement of height, from longest amputation site to top of head. Weight is to be entered in pounds, and is to be a facility measured weight. The chosen weight for the MDS is the weight that is closest to the ARD date, but not taken after the ARD date.
The significant weight changes questioned about in next section are only referring to one month significant weight change and six month significant weight change. These weight changes are determined by the weight entered in this MDS, and the date of the weight taken to determine 30 day comparison and 180 day comparison. Next is to decide if the weight change is physician-ordered or unexpected. To be a physician ordered weight loss, it could be related to a diuretic causing diuresis-related weight loss or doctor ordered therapeutic diet that restricts calories for weight loss. Physician ordered weight gain would be a gain that occurs when there has been an ordered intervention that increases calories or appetite, i.e. high calorie diet, nutritional supplements, or appetite stimulants.
The next section of questions reviews current interventions in place for the resident. The Intravenous Fluids should be marked only when used for hydration, not for IV medications, or IV flushes to keep the line patent. This is also marked yes when Total Parental Nutrition is present. Next is questioning if a feeding tube is present: yes or no. It’s not asking if it’s being used for nutrition, but if the feeding tube is present. There are times the feeding tube is just being flushed to keep it open.
A mechanically altered diet is triggered when foods are specifically prepared to alter the texture or consistency of food or fluids to facilitate oral intake. Examples include soft solids, puréed foods, ground meat, and thickened liquids. A mechanically altered diet should not automatically be considered a therapeutic diet.
Therapeutic diets are not defined by the content of what is provided or when it is served, but why the diet is required. Therapeutic diets provide the corresponding treatment that addresses a particular disease or clinical condition. Therapeutic diets can range from diabetic diet, NAS diet, or even general diet with nutritional supplements to support wound healing, or general diet with double protein at meals if that double serving of protein is for wound healing or weight gain. Goal is to determine in initial assessment the required nutritional therapy and best nutritional intervention. Therapeutic diet can also be triggered if using a disease specific tube feeding product, i.e. Glucerna, Nepro.
Next part of section K is labeled “Percent Intake by Artificial Intake”. This section is only triggered if parental/IVF or tube feeding were triggered. When determining how much of resident’s nutritional needs were met by the TF or the IVs, one needs to decide if there are other routes of nutritional intake. For example, if resident has only TF and is NPO, then 100% of resident needs are met by the tube feeding, even if the tube feeding is not meeting the calculated needs. It’s only asking source of nutrition. Residents that have oral intake and tube fed, calorie counts are desired to determine the percentage the oral intake provides versus tube feeding to meet estimated nutritional needs.
Fluid intake via IV/TF is more black and white. Fluid intake is calculated for the average intake via feeding tube and intravenous fluids over the 7 day observation or look back period. The only time this can be difficult is if IVFs are given for 1 or 2 day period and this total volume needs to be divided by 7 to determine the average daily IVF intake. Working with facility MDS coordinator on these type of questions is always the best option if uncertain.
The MDS, Minimum Data Set, is an assessment tool for long term care. As nutritional professionals, we usually assume responsibility for filling out section K covering nutritional status. We can gather the information using our resources and utilize all team members to complete accurately.