regulation & survey process related to nutrition & hydration brenda buroker, rn, isdh survey...
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Regulation & Survey Process Related to
Nutrition & HydrationBrenda Buroker, RN, ISDH Survey ManagerDonna Downs, RN, ISDH Area Supervisor
Indiana HealthcareLeadership Conference
March 31, 2011
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 AppearanceHeightWeight
Current Standard of Practice for WeighingAdmission /ReadmissionWeekly for first 4 weeksMonthly Significant Change in Condition
ASSESSMENT
Food and Fluid intakeAltered Nutrient intake
Inability to consume meals provided
Insufficient availability of food
Environmental factorsMedicationsDisease or condition
• Chewing abnormalities
• Swallowing abnormalities
• Functional ability• Medications• Goals and prognosis• Laboratory Test
Serum AlbuminPre-albumin
ANALYSIS & EVALUATION
RAI InformationInformation from assessmentReview / Analyze informationIdentify or determine status
Risk for unplanned weight lossAble to maintain acceptable parameters
WEIGHT LOSS PARAMETERS
INTERVAL SIGNIFICANT SEVERE
1 month 5% >5%
3 months 7.5% >7.5%
6 months 10%>10%
CARE PLANNING & INTERVENTIONS
Resident Choice Meet Nutritional
NeedsDiet LiberalizationWeight – Related
InterventionsWeight GainEnvironmental
FactorsAnorexiaWound Healing
Functional FactorsChewing &
SwallowingMedicationsFood Fortification &
SupplementationFluid & ElectrolyteAppetite StimulantsFeeding TubesEnd-of-Life
MONITORING
Identifying and Reporting InformationLevel of consciousness & functionPain or discomfortFluctuating appetiteNausea or GI symptoms
Emergence of new risk factorsAcute medical illnessPressure 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 appearanceDining observationsDelivery of careServing of foodResponse to resident’s needsDifferences between observations and care
plan /interventions
INVESTIGATIVE PROTOCOL INTERVIEW
RESIDENT, FAMILY OR REPRESENTATIVENecessary equipmentPreferencesChoices / SubstitutionsSupplements / SnacksRefusal of therapeutic approaches
explained
INVESTIGATIVE PROTOCOL INTERVIEW
STAFF – (Direct care & interdisciplinary team members)
Intake monitored and reportedNutritional interventionsCommunication related to care plan and
interventionsReport of changes
INVESTIGATIVE PROTOCOL RECORD REVIEW
Evaluated & analyzed nutritional statusIdentified nutritional riskInvestigated causes of impaired nutritional
statusIdentified & implemented nutritional
interventionsIdentified RAI triggeredEvaluated effectiveness of interventionsMonitored & 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 TAGSF150 – Resident RightsF272 – Comprehensive
AssessmentsF279 – Comprehensive
Care PlansF280 – Comprehensive
Care Plan RevisionF282 – Provision of
Care in Accordance with the Care Plan
F327– HydrationF328 – Special Needs
F329 –Unnecessary Drugs
F353 – Sufficient StaffF361 – Dietary ServicesF362 – Standard
Sufficient StaffF385 – Physician
ServicesF500 – Use of Outside
ResourcesF501 – Medical DirectorF522 – 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 ccException is renal / cardiac residents
PROBES
• Clinical signs of insufficient fluids observed
• Laboratory results – abnormal
• Facility actions• Identify risk factors• Care provided• Alternative treatment
QUALITYINDICATOR
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 residentsADMISSION SAMPLE – up to 30 residents
Current or Closed RecordsFood choices – not part of Admission Sample
criteriaTerminal Diagnosis
WEIGHTS REVIEWEDTimeframe in the facilityPotential trigger if weight loss occurred
QIS -- RECORD REVEIW
Planned weight loss programHeight recordedDate & weight closest to admissionDate & weight closest to 15 days after
admissionDate & weight closest to day 30 after admissionDate & weight closest to day 60 after admission
QIS
ASE-Q calculates the requested dates and percentage of weight loss.
Critical Elements PathwayNutrition -- noneHydration -- 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 PlanInterventions Implementation Individual Needs – identified and addressedPlan/Interventions are successfulRevisions if necessary
THANK YOU