Cheerful Mid Adult Businesswoman

Proper nutrition is vital for healthy aging.  If monitored improperly, elderly residents can very quickly become malnourished, often leading to a myriad of physical complications including pressure ulcers, decreased cognitive function, and impaired quality of life.  Nutrition also may affect a resident’s emotional well-being and willingness to participate in daily activities.  CMS regulatory requirements state it is important to maintain adequate nutritional status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being.   There is an expectation that there is ongoing communication and coordination among and between staff within all departments to ensure that daily nutritional and dietary needs and choices are being met.

A resident’s nutrition status affects their overall well-being; therefore, a team effort is needed to prevent and treat nutritional decline.  All members of a facility’s interdisciplinary team have a role in devising creative ways to enhance resident nutrition, such as activity professionals offering healthy snacks during daily programs, therapists providing foods during their therapy sessions, or nurses providing high nutrition liquids during med passes.  The early identification of residents with, or at risk for, impaired nutrition or hydration status may allow the interdisciplinary team to develop and implement interventions to stabilize or improve nutritional status before complications arise.

A Nutrition at Risk Meeting (NAR) is a great tool to identify residents who may be at nutrition risk and discussed amongst the interdisciplinary team.  The NAR team may consist of the following interdisciplinary team members: Dietitian, Dietary Supervisor, Director of Nursing, charge nurses and/or restorative nurse, nursing assistants, speech-language pathologist, social services and/or activities director.

Components of an effective NAR program consists of:

  • Team collaboration to identify residents to be discussed at the meeting
    • New admissions/readmissions for minimum of 4 weeks
    • Individuals with new tube feeding or total parenteral nutrition
    • Individuals transitioning from tube feeding to oral feeding with recent decreases in tube feeding orders to promote increased oral intake
    • Those with less than 50% food intake for 3 days (9 consecutive meals), until intake is stable
    • Those identified as being at risk or having malnutrition or undernutrition
    • Significant unintended weight changes, or insidious weight loss, until stable
    • Pressure injuries
    • Fluid imbalance (i.e. dehydration, over-hydration)
    • Dialysis
    • Those receiving thickened liquids, or fluid restrictions
  • Each team member comes to the meeting prepared with information to share with the IDT
    • Weight Trend
    • Diet tolerance
    • Meal Assistance & Average appetite/intakes
    • Supplement, Fortified/Enhanced items intake and acceptance
    • New Diagnosis or Recent Change in Condition
    • Physical Appearance
    • Functional Ability
    • Nutrition Related Labs
    • Skin Condition
    • Behaviors including Psychoactive medication/behavior management treatment.
    • Falls/Incidents/Accidents
  • Meet no less than monthly, or more frequently as needed to appropriately meet the needs of at- risk residents
  • Clinical documentation in the medical record completed according to the results of the interdisciplinary team’s decisions and care plan updated
  • Immediate interventions are implemented by the facility, as appropriate, to prevent further decline
  • Monitor until the resident’s condition resolves or stabilizes and no longer needs frequent monitoring or as determined by NAR team members

Weight loss, poor nutritional status, or dehydration should be considered avoidable unless the facility can prove it has assessed/reassessed the resident’s needs, consistently implemented related care planned interventions, monitored for effectiveness, and ensured coordination of care among the interdisciplinary team.  Early identification of risk factors, regardless of the presence of any associated weight changes, can help the facility choose appropriate interventions to minimize any subsequent complications.  By increasing staff members’ awareness and fostering their input in the development of innovative solutions a resident’s nutritional status will be improved.  With proper procedures in place, undernourishment will be mitigated, skin integrity preserved, and cognitive, social, and physical function will be protected and enhanced.

Sources:

1)Centers for Medicare and Medicaid Services.  State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, (2017). https://www.cms.gov/Regulations-and-Guidadefnce/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf