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2/12/2014
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CURRENT “BEST
PRACTICE”
Presenter:
Brenda Richardson MA, RDN, LD, CD
Standards for
Nutrition in Long
Term Care
Objectives- Attendees can:
• Identify current Best Practice standards with
Nutrition and Aging.
• Discuss current Best Practice standards with
Nutrition related to Wounds, and Hydration
• Know available Best Practice Resources to
support implementation at the Facility Level
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WHY FOCUS ON NUTRITION?
Malnutrition is a major contributor Malnutrition is a major contributor Malnutrition is a major contributor Malnutrition is a major contributor to: to: to: to:
• increased morbidity and mortality,
• decreased function and quality of life,
• increased frequency and length of
hospital stay, and
• higher health care costs.
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•Federal
•State
•Professional
Organizations
•Identify the Team
•Team
Responsibilites
•Staff/Residents/
Families
•Programs
•Policies/Procedures
• Training/Education
• QI/QAPI Customers
•Vendors/Contracts
I. Know what I. Know what I. Know what I. Know what
”Best Practice” ”Best Practice” ”Best Practice” ”Best Practice”
Is for LTCIs for LTCIs for LTCIs for LTC
II. Facility II. Facility II. Facility II. Facility
Team Team Team Team
ManagementManagementManagementManagement
III. Facility III. Facility III. Facility III. Facility
Systems and Systems and Systems and Systems and
ProcessesProcessesProcessesProcesses
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RESOURCES:
•Federal
• State
• Professional Organizations
I. Know I. Know I. Know I. Know whatwhatwhatwhat
Nutrition ”Best Nutrition ”Best Nutrition ”Best Nutrition ”Best
Practice” Is for Practice” Is for Practice” Is for Practice” Is for
LTCLTCLTCLTC
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VISULIZE ACTIVITIES WITH TIMELINES!
AARPAND AHCAHEALTH
DEPTMDS NPUAP ANFP AAHSAQUALITYSOM
ProfessionalProfessionalProfessionalProfessional
Organizations Organizations Organizations Organizations
(AND, AMDA, (AND, AMDA, (AND, AMDA, (AND, AMDA,
NPUAP, CDC, etc.NPUAP, CDC, etc.NPUAP, CDC, etc.NPUAP, CDC, etc.
State and State and State and State and
Federal Gov Federal Gov Federal Gov Federal Gov
Agencies (CMS, Agencies (CMS, Agencies (CMS, Agencies (CMS,
SDH, Health SDH, Health SDH, Health SDH, Health
Dept, AoA, etc) Dept, AoA, etc) Dept, AoA, etc) Dept, AoA, etc)
CONSUMER & CONSUMER & CONSUMER & CONSUMER &
Consumer Consumer Consumer Consumer
Organizations Organizations Organizations Organizations
(AARP, NCOA, (AARP, NCOA, (AARP, NCOA, (AARP, NCOA,
etc) etc) etc) etc)
Examples of Resources for Best Practice
Others: QIOs, Pioneer Network, USDA, CDC, FDA, AMDA, ASPEN, etc.
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REMEMBER THAT “WHATEVER NUTRITION
ASSESSMENT AND CARE PLANNING
RESOURCES ARE USED, THEY ARE EXPECTED
TO BE:
- CURRENT,
- EVIDENCE-BASED OR EXPERT-
ENDORSED RESEARCH AND CLINICAL
PRACTICE GUIDELINES/RESOURCES”
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• Nursing
• Registered Dietitian
• Dietary Manager/ Diet Technician Registered
• Speech Language Pathologist
• Quality Improvement
• Medical Director
• CNAs
• Others (Pharmacist, Occupational Therapist, etc.)
Identify Identify Identify Identify a Nutrition a Nutrition a Nutrition a Nutrition
“Oversight” “Oversight” “Oversight” “Oversight” TeamTeamTeamTeam
II. Facility Team II. Facility Team II. Facility Team II. Facility Team
ManagementManagementManagementManagement
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• Nursing/ Director of Nursing, Unit Mgrs, CNAs, others
• Registered Dietitian (Licensure/Certification, Skills and
Competencies, Professional Involvement)
• Dietary Manager/ Diet Technician Registered
• Speech Language Pathologist
• Quality Improvement
• Medical Director
• Others (Pharmacist, Occupational Therapist, etc.)
Identify Identify Identify Identify Team Team Team Team
ResponsibilitiesResponsibilitiesResponsibilitiesResponsibilities
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• In-services
• Newsletters/memos
• Department Head Meetings
• Change in Shift Meetings
• Care Plan Meetings
• Others (Website, etc)
Communication Communication Communication Communication
with Staff, with Staff, with Staff, with Staff,
Residents and Residents and Residents and Residents and
FamiliesFamiliesFamiliesFamilies
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III. SystemsIII. SystemsIII. SystemsIII. Systems
And ProcessesAnd ProcessesAnd ProcessesAnd Processes
• Key Facility Nutrition Programs
• Nutrition Manuals/Care Manuals
• Menus and Vendor Programs
• Customer Satisfaction
• Quality Improvement11
III. SystemsIII. SystemsIII. SystemsIII. Systems
And ProcessesAnd ProcessesAnd ProcessesAnd Processes
• Key Facility Nutrition Programs
- Food service and Dining programs
- High Risk Nutrition
- Weight monitoring program
- Hydration program
- Skin and wound care program
- Real Food/Nutritional supplement program
- Quality Improvement program 12
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III. SystemsIII. SystemsIII. SystemsIII. Systems
And ProcessesAnd ProcessesAnd ProcessesAnd Processes
Manuals:
• Policy/Procedure Manuals:
• Current, Best Practice, Reflect What your
Facility Does, Staff is educated/trained.
• Diet Manual:
• Current and Best Practice
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III. SystemsIII. SystemsIII. SystemsIII. Systems
And ProcessesAnd ProcessesAnd ProcessesAnd Processes
Manuals: State Operations Manual (SOM)
•Requirements in 42 CFR Part 483, Subpart B,
• Know The Survey Process, Survey Forms,
Appendix P - Survey Protocol for Long Term Care
Facilities - Part I and Appendix PP- Guidance to
Surveyors for LTC Facilities
• Know the Deficiency Criteria and Determination
and the Plans of Correction
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III. SystemsIII. SystemsIII. SystemsIII. Systems
And ProcessesAnd ProcessesAnd ProcessesAnd Processes
Manuals:
• RAI Manual
• Additional References
• Client Education Material
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III. SystemsIII. SystemsIII. SystemsIII. Systems
And ProcessesAnd ProcessesAnd ProcessesAnd Processes
Customer Satisfaction - Resident Council,
Newsletters, Surveys
- Be present during all meals and get input.
- Provide follow-up and responsiveness.
Culture Change: - “Self-Directed Living” “Informed
Choice” “Options” - Pioneer Network, CMS Survey
& Certification Process
Quality Improvement: - Nutrition Programs,
Weights, Heights, QI/QAPI, Dining, etc.16
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NUTRITION/WOUNDS/HYDRATION
NutritionNutritionNutritionNutrition
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NUTRITION F325 SOM
§§§§483.25(i) Nutrition483.25(i) Nutrition483.25(i) Nutrition483.25(i) Nutrition
Based on a resident’s comprehensive assessment, the facility Based on a resident’s comprehensive assessment, the facility Based on a resident’s comprehensive assessment, the facility Based on a resident’s comprehensive assessment, the facility
must ensure that a residentmust ensure that a residentmust ensure that a residentmust ensure that a resident--------
§§§§483.25(i)(1) Maintains acceptable parameters of nutritional 483.25(i)(1) Maintains acceptable parameters of nutritional 483.25(i)(1) Maintains acceptable parameters of nutritional 483.25(i)(1) Maintains acceptable parameters of nutritional
status, such as body weight and protein levels, unless the status, such as body weight and protein levels, unless the status, such as body weight and protein levels, unless the status, such as body weight and protein levels, unless the
resident’s clinical condition demonstrates that this is not resident’s clinical condition demonstrates that this is not resident’s clinical condition demonstrates that this is not resident’s clinical condition demonstrates that this is not
possible; andpossible; andpossible; andpossible; and
§§§§483.25(i)(2) Receives a therapeutic diet when there is a 483.25(i)(2) Receives a therapeutic diet when there is a 483.25(i)(2) Receives a therapeutic diet when there is a 483.25(i)(2) Receives a therapeutic diet when there is a
nutritional problem.nutritional problem.nutritional problem.nutritional problem.
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Source: State Operations Manual
Appendix PP - Guidance to Surveyors for Long Term Care Facilities
Accessed Online 2 8 2014)
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NUTRITION F325 SOM
INTENT: INTENT: INTENT: INTENT: §§§§483.25(i) Nutritional Status483.25(i) Nutritional Status483.25(i) Nutritional Status483.25(i) Nutritional Status
The intent of this requirement is that the resident maintains, to the extent The intent of this requirement is that the resident maintains, to the extent The intent of this requirement is that the resident maintains, to the extent The intent of this requirement is that the resident maintains, to the extent
possible, acceptable parameters of nutritional status and that the facility:possible, acceptable parameters of nutritional status and that the facility:possible, acceptable parameters of nutritional status and that the facility:possible, acceptable parameters of nutritional status and that the facility:
• Provides nutritional care and services to each resident, consistent with the • Provides nutritional care and services to each resident, consistent with the • Provides nutritional care and services to each resident, consistent with the • Provides nutritional care and services to each resident, consistent with the
resident’s comprehensive assessment;resident’s comprehensive assessment;resident’s comprehensive assessment;resident’s comprehensive assessment;
• Recognizes, evaluates, and addresses the needs of every resident, including • Recognizes, evaluates, and addresses the needs of every resident, including • Recognizes, evaluates, and addresses the needs of every resident, including • Recognizes, evaluates, and addresses the needs of every resident, including
but not limited to, the resident at risk or already experiencing impaired but not limited to, the resident at risk or already experiencing impaired but not limited to, the resident at risk or already experiencing impaired but not limited to, the resident at risk or already experiencing impaired
nutrition; andnutrition; andnutrition; andnutrition; and
• Provides a therapeutic diet that takes into account the resident’s clinical • Provides a therapeutic diet that takes into account the resident’s clinical • Provides a therapeutic diet that takes into account the resident’s clinical • Provides a therapeutic diet that takes into account the resident’s clinical
condition, and preferences, when there is a nutritional indication.condition, and preferences, when there is a nutritional indication.condition, and preferences, when there is a nutritional indication.condition, and preferences, when there is a nutritional indication.
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Revised in 2010
Using a “Best Practice” Clinical Practice Guideline
(AMDA) “Altered
Nutritional Status in the Long-Term
Care Setting”AMDA – Dedicated to Long Term Care Medicine (AMDA), the professional association of medical
directors, attending physicians, and others practicing in the long term care continuum, is
dedicated to excellence in patient care and provides education, advocacy, information, and
professional development to promote the delivery of quality long term care medicine.
www.amda.com20
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Altered Nutritional Status (ANS): Unintended
and unexpected change in weight that is likely
to indicate an undesired alteration in intake or
utilization of nutrients.
CPG Guidelines (27 steps):
RECOGNITION – Steps 1 - 3
ASSESSMENT – Steps 4 - 14
TREATMENT – Steps 15 - 22
MONITORING – Steps 23 - 27
Definition of Altered Definition of Altered Definition of Altered Definition of Altered Nutritional Status (ANS): Nutritional Status (ANS): Nutritional Status (ANS): Nutritional Status (ANS):
Unintended and unexpected change in weight Unintended and unexpected change in weight Unintended and unexpected change in weight Unintended and unexpected change in weight
that is likely to indicate an undesired alteration that is likely to indicate an undesired alteration that is likely to indicate an undesired alteration that is likely to indicate an undesired alteration
in intake or utilization of nutrientsin intake or utilization of nutrientsin intake or utilization of nutrientsin intake or utilization of nutrients....
Note: Differentiate Protein-Energy
Undernutrition (PEU), Cachexia, and Sarcopenia
from Altered Nutritional Status (ANS).
(Although these may present as ANS)
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CHARACTERISTICS RECOMMENDED FOR THE
IDENTIFICATION AND DOCUMENTATION OF ADULT
MALNUTRITION (UNDERNUTRITION)
The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend that a standardized set of diagnostic characteristics be used to identify and document adult malnutrition in routine clinical practice.
An etiologically based diagnostic nomenclature that incorporates a current understanding of the role of the inflammatory response on malnutrition’s incidence, progression, and resolution was proposed.
SourceSourceSourceSource: This article : This article : This article : This article was simultaneously was simultaneously was simultaneously was simultaneously published published published published in the in the in the in the May 2012 issues of the May 2012 issues of the May 2012 issues of the May 2012 issues of the Journal of Journal of Journal of Journal of the Academy the Academy the Academy the Academy of Nutrition and Dietetics and of Nutrition and Dietetics and of Nutrition and Dietetics and of Nutrition and Dietetics and the Journal the Journal the Journal the Journal of Parenteral and of Parenteral and of Parenteral and of Parenteral and Enteral Enteral Enteral Enteral Nutrition J Nutrition J Nutrition J Nutrition J Acad Nutr Diet. 2012;112:730Acad Nutr Diet. 2012;112:730Acad Nutr Diet. 2012;112:730Acad Nutr Diet. 2012;112:730----738738738738....
www.eatright.orgwww.eatright.orgwww.eatright.orgwww.eatright.org
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Dining Practice Standards &
CMS Support
www.pioneernetwork.net
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Why were Dining Standards created?
Food and Dining are core components of quality of life and quality of care.
How are we currently doing?
- Food consumption
- Supplement Usage
- Weight loss
- Malnutrition
- Customer Satisfaction
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Why were these standards created?
1. Food consumption: 50-70% of residents leave 25% or more of their food uneaten
2. Supplement Usage: 60-80% of residents have an order for a dietary supplement
3. Weight loss: 25% of residents experienced weight loss when research staff conducted standardized weighing procedures over time
4. Malnutrition/Under-nutrition: 23-85% prevalence
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4. Food and Dining: Integral part of individualized care and self-directed living
• Food and dining requirements are complex when advancing models of culture change
• Food and dining are significant elements of daily living
• CMS receives more questions and concerns focused on dining and food policies in nursing homes than any other area.
Why?- continued
Food and Dining Clinical
Standards Task Force
This task force was comprised of:▫ symposium experts and national standard
setting (from many different organizations)▫ Goal : “Establish nationally agreed upon
new standards of practice supporting individualized care and self-directed living versus traditional diagnosis-focused treatment.”
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Who supports the standards?• American Association for Long Term Care Nursing (AALTCN)• American Association of Nurse Assessment Coordination (AANAC)• Academy of Nutrition and Dietetics (formerly American Dietetic
Association (ADA))• American Medical Directors Association (AMDA)• American Occupational Therapy Association (AOTA)• American Society of Consultant Pharmacists (ASCP)• American Speech-Language-Hearing Association (ASHA)• Association of Nutrition and Foodservice Professionals (ANFP)• Gerontological Advanced Practice Nurses Association (GAPNA)• Hartford Institute for Geriatric Nursing (HIGN) • National Association of Directors of Nursing Administration in Long Term
Care (NADONA/LTC)• National Gerontological Nursing Association (NGNA)Representatives from Centers for Medicare & Medicaid Services Division of Nursing Homes, the US Food & Drug Administrators & the Centers for Disease Control & Prevention
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The Dining Practice Standards Document
Includes the following new Standards of Practice:
1. Individualized Nutrition Approaches/Diet Liberalization 2. Diabetic/Calorie Controlled Diet 3. Low Sodium Diet 4. Cardiac Diet 5. Altered Consistency Diet 6. Tube Feeding 7. Real Food First 8. Honoring Choices 9. Shifting Traditional Professional Control to Support Self
Directed Living10. New Negative Outcome Focus
* Issued by the Pioneer Network Sept. 7, 2011
www.pioneernetwork.net
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The STANDARDS
NOTE:
• Focuses on ELDERLY population in LTC facilities
• However, the document’s overarching theme is the support of individualized care and of resident’s choice, which applies to all age groups.
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March 1,
2013 CMS
S&C:13-
13-NH
Information Only: New Dining Standards of Practice Resources are Available
Summary:
New Dining Practice Standards
Expanding Diet Options for Older Individuals
Surveyor Training Video:
http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1101
NUTRITION/WOUNDS/HYDRATION
WoundsWoundsWoundsWounds
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PRESSURE SORES & NUTRITION F314 SOM
§§§§483.25(c483.25(c483.25(c483.25(c) Pressure Sores) Pressure Sores) Pressure Sores) Pressure Sores
Based on the comprehensive Assessment of a resident, the facility must ensure Based on the comprehensive Assessment of a resident, the facility must ensure Based on the comprehensive Assessment of a resident, the facility must ensure Based on the comprehensive Assessment of a resident, the facility must ensure
thatthatthatthat--------
(1) A resident who enters the facility without pressure sores does not develop (1) A resident who enters the facility without pressure sores does not develop (1) A resident who enters the facility without pressure sores does not develop (1) A resident who enters the facility without pressure sores does not develop
pressure sores unless the individual’s clinical condition demonstrates that pressure sores unless the individual’s clinical condition demonstrates that pressure sores unless the individual’s clinical condition demonstrates that pressure sores unless the individual’s clinical condition demonstrates that
they were unavoidable; andthey were unavoidable; andthey were unavoidable; andthey were unavoidable; and
(2) A resident having pressure sores receives necessary treatment and services (2) A resident having pressure sores receives necessary treatment and services (2) A resident having pressure sores receives necessary treatment and services (2) A resident having pressure sores receives necessary treatment and services
to promote healing, prevent infection and prevent new sores from developing.to promote healing, prevent infection and prevent new sores from developing.to promote healing, prevent infection and prevent new sores from developing.to promote healing, prevent infection and prevent new sores from developing.
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PRESSURE SORES & NUTRITION F314 SOM
Intent: (F314) 42 CFR 483.25(c)Intent: (F314) 42 CFR 483.25(c)Intent: (F314) 42 CFR 483.25(c)Intent: (F314) 42 CFR 483.25(c)
The intent of this requirement is that the resident does not develop pressure The intent of this requirement is that the resident does not develop pressure The intent of this requirement is that the resident does not develop pressure The intent of this requirement is that the resident does not develop pressure
ulcers unless clinically unavoidable and that the facility provides care and ulcers unless clinically unavoidable and that the facility provides care and ulcers unless clinically unavoidable and that the facility provides care and ulcers unless clinically unavoidable and that the facility provides care and
services to:services to:services to:services to:
• Promote the prevention of pressure ulcer development;• Promote the prevention of pressure ulcer development;• Promote the prevention of pressure ulcer development;• Promote the prevention of pressure ulcer development;
• Promote the healing of pressure ulcers that are present (including prevention • Promote the healing of pressure ulcers that are present (including prevention • Promote the healing of pressure ulcers that are present (including prevention • Promote the healing of pressure ulcers that are present (including prevention
of infection to the extent possible); andof infection to the extent possible); andof infection to the extent possible); andof infection to the extent possible); and
• Prevent development of additional pressure ulcers.• Prevent development of additional pressure ulcers.• Prevent development of additional pressure ulcers.• Prevent development of additional pressure ulcers.
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UNDER-NUTRITION AND HYDRATION DEFICITS F314 SOM
Adequate Adequate Adequate Adequate nutrition and hydration are essential for overall nutrition and hydration are essential for overall nutrition and hydration are essential for overall nutrition and hydration are essential for overall
functioning. Nutrition provides vital energy and building blocks functioning. Nutrition provides vital energy and building blocks functioning. Nutrition provides vital energy and building blocks functioning. Nutrition provides vital energy and building blocks
for all of the body’s structures and processes. Any organ or for all of the body’s structures and processes. Any organ or for all of the body’s structures and processes. Any organ or for all of the body’s structures and processes. Any organ or
body system may require additional energy or structural body system may require additional energy or structural body system may require additional energy or structural body system may require additional energy or structural
materials for repair or function. materials for repair or function. materials for repair or function. materials for repair or function.
The The The The skin is the body’s largest organ system. It may affect, and be skin is the body’s largest organ system. It may affect, and be skin is the body’s largest organ system. It may affect, and be skin is the body’s largest organ system. It may affect, and be
affected by, other body processes and organs. Skin condition affected by, other body processes and organs. Skin condition affected by, other body processes and organs. Skin condition affected by, other body processes and organs. Skin condition
reflects overall body function; skin breakdown may be the reflects overall body function; skin breakdown may be the reflects overall body function; skin breakdown may be the reflects overall body function; skin breakdown may be the
most visible evidence of a general catabolic state.most visible evidence of a general catabolic state.most visible evidence of a general catabolic state.most visible evidence of a general catabolic state.
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The Role of Nutrition in Pressure Ulcer The Role of Nutrition in Pressure Ulcer The Role of Nutrition in Pressure Ulcer The Role of Nutrition in Pressure Ulcer
Prevention and TreatmentPrevention and TreatmentPrevention and TreatmentPrevention and Treatment: NPUAP: NPUAP: NPUAP: NPUAP
- Early nutrition screening and assessment
- Energy
- Protein
- Fluids
- Vitamins/Minerals
- AA:Arginine-Glutamine; Micronutrients: Vitamin C/
/Zinc/Copper
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NPUAP WHITE PAPERWWW.NPUAP.ORG
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NUTRITION/WOUNDS/HYDRATION
HydrationHydrationHydrationHydration
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FLUID/HYDRATION F327 SOM
§§§§483.25(j483.25(j483.25(j483.25(j) Hydration. The facility must provide each resident with sufficient ) Hydration. The facility must provide each resident with sufficient ) Hydration. The facility must provide each resident with sufficient ) Hydration. The facility must provide each resident with sufficient
fluid intake to maintain proper hydration and fluid intake to maintain proper hydration and fluid intake to maintain proper hydration and fluid intake to maintain proper hydration and healthhealthhealthhealth
Intent Intent Intent Intent §§§§483.25(j)483.25(j)483.25(j)483.25(j)
The intent of this regulation is to assure that the resident receives sufficient The intent of this regulation is to assure that the resident receives sufficient The intent of this regulation is to assure that the resident receives sufficient The intent of this regulation is to assure that the resident receives sufficient
amount of fluids based on individual needs to prevent dehydration.amount of fluids based on individual needs to prevent dehydration.amount of fluids based on individual needs to prevent dehydration.amount of fluids based on individual needs to prevent dehydration.
Interpretive Guidelines Interpretive Guidelines Interpretive Guidelines Interpretive Guidelines §§§§483.25(j)483.25(j)483.25(j)483.25(j)
“Sufficient fluid” means the amount of fluid needed to prevent dehydration “Sufficient fluid” means the amount of fluid needed to prevent dehydration “Sufficient fluid” means the amount of fluid needed to prevent dehydration “Sufficient fluid” means the amount of fluid needed to prevent dehydration
(output of fluids far exceeds fluid intake) and maintain health. The amount (output of fluids far exceeds fluid intake) and maintain health. The amount (output of fluids far exceeds fluid intake) and maintain health. The amount (output of fluids far exceeds fluid intake) and maintain health. The amount
needed is specific for each resident, and fluctuates as the resident’s needed is specific for each resident, and fluctuates as the resident’s needed is specific for each resident, and fluctuates as the resident’s needed is specific for each resident, and fluctuates as the resident’s
condition fluctuates (e.g., increase fluids if resident has fever or diarrhea).condition fluctuates (e.g., increase fluids if resident has fever or diarrhea).condition fluctuates (e.g., increase fluids if resident has fever or diarrhea).condition fluctuates (e.g., increase fluids if resident has fever or diarrhea).
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F325
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HYDRATION F327 SOM
Risk factors for the resident becoming dehydrated are:Risk factors for the resident becoming dehydrated are:Risk factors for the resident becoming dehydrated are:Risk factors for the resident becoming dehydrated are:
• Coma/decreased sensorium;• Coma/decreased sensorium;• Coma/decreased sensorium;• Coma/decreased sensorium;
• Fluid loss and increased fluid needs (e.g., diarrhea, fever, uncontrolled • Fluid loss and increased fluid needs (e.g., diarrhea, fever, uncontrolled • Fluid loss and increased fluid needs (e.g., diarrhea, fever, uncontrolled • Fluid loss and increased fluid needs (e.g., diarrhea, fever, uncontrolled
diabetes);diabetes);diabetes);diabetes);
• Fluid restriction secondary to renal dialysis;• Fluid restriction secondary to renal dialysis;• Fluid restriction secondary to renal dialysis;• Fluid restriction secondary to renal dialysis;
• Functional impairments that make it difficult to drink, reach fluids, or • Functional impairments that make it difficult to drink, reach fluids, or • Functional impairments that make it difficult to drink, reach fluids, or • Functional impairments that make it difficult to drink, reach fluids, or
communicate fluid needs (e.g., aphasia);communicate fluid needs (e.g., aphasia);communicate fluid needs (e.g., aphasia);communicate fluid needs (e.g., aphasia);
• Dementia in which resident forgets to drink or forgets how to drink;• Dementia in which resident forgets to drink or forgets how to drink;• Dementia in which resident forgets to drink or forgets how to drink;• Dementia in which resident forgets to drink or forgets how to drink;
• Refusal of fluids; and• Refusal of fluids; and• Refusal of fluids; and• Refusal of fluids; and
• Did the MDS trigger any CAAs for dehydration? What action was taken based • Did the MDS trigger any CAAs for dehydration? What action was taken based • Did the MDS trigger any CAAs for dehydration? What action was taken based • Did the MDS trigger any CAAs for dehydration? What action was taken based
on this information?on this information?on this information?on this information?
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DETERMINING BASELINE DAILY FLUIDS DETERMINING BASELINE DAILY FLUIDS DETERMINING BASELINE DAILY FLUIDS DETERMINING BASELINE DAILY FLUIDS
• A general guideline for determining baseline daily
fluids needs is to multiply the resident’s body weight
in kg times 30cc (2.2 lbs = 1kg),
• except for residents with renal or cardiac distress. An
excess of fluids can be detrimental for these
residents. (1)
• Other Factors to Consider (2)
42
1. State Operations Manual PP- Guidance to Surveyors for Long Term Care Facilities.
Accessed online 2/8/2014.
2. Pocket Resource for Nutrition Assessment 2013 Edition, Dietetics in Health Care
Communities, a dietetic practice group of the Academy of Nutrition and Dietetics
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F327 HYDRATION: SOM
Probes: Probes: Probes: Probes: §§§§483.25(j)483.25(j)483.25(j)483.25(j)
Do sampled residents show clinical signs of possible insufficient fluid intake (e.g., dry skin and Do sampled residents show clinical signs of possible insufficient fluid intake (e.g., dry skin and Do sampled residents show clinical signs of possible insufficient fluid intake (e.g., dry skin and Do sampled residents show clinical signs of possible insufficient fluid intake (e.g., dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, fever), abnormalmucous membranes, cracked lips, poor skin turgor, thirst, fever), abnormalmucous membranes, cracked lips, poor skin turgor, thirst, fever), abnormalmucous membranes, cracked lips, poor skin turgor, thirst, fever), abnormal
laboratory values (e.g., elevated hemoglobin and hematocrit, potassium, chloride, sodium, albumin, laboratory values (e.g., elevated hemoglobin and hematocrit, potassium, chloride, sodium, albumin, laboratory values (e.g., elevated hemoglobin and hematocrit, potassium, chloride, sodium, albumin, laboratory values (e.g., elevated hemoglobin and hematocrit, potassium, chloride, sodium, albumin, transferrin, blood urea nitrogen (BUN), or urine specific gravity)?transferrin, blood urea nitrogen (BUN), or urine specific gravity)?transferrin, blood urea nitrogen (BUN), or urine specific gravity)?transferrin, blood urea nitrogen (BUN), or urine specific gravity)?
Has the facility provided residents with adequate fluid intake to maintain proper hydration and health? Has the facility provided residents with adequate fluid intake to maintain proper hydration and health? Has the facility provided residents with adequate fluid intake to maintain proper hydration and health? Has the facility provided residents with adequate fluid intake to maintain proper hydration and health? If not:If not:If not:If not:
• Did the facility identify any factors that put the resident at risk of dehydration?• Did the facility identify any factors that put the resident at risk of dehydration?• Did the facility identify any factors that put the resident at risk of dehydration?• Did the facility identify any factors that put the resident at risk of dehydration?
• What care did the facility provide to reduce those risk factors and ensure adequate fluid intake (e.g., • What care did the facility provide to reduce those risk factors and ensure adequate fluid intake (e.g., • What care did the facility provide to reduce those risk factors and ensure adequate fluid intake (e.g., • What care did the facility provide to reduce those risk factors and ensure adequate fluid intake (e.g., keep fluids next to the resident at all times and assisting or cuing the resident to drink)? Is staff keep fluids next to the resident at all times and assisting or cuing the resident to drink)? Is staff keep fluids next to the resident at all times and assisting or cuing the resident to drink)? Is staff keep fluids next to the resident at all times and assisting or cuing the resident to drink)? Is staff aware of need for maintaining adequate fluid intake?aware of need for maintaining adequate fluid intake?aware of need for maintaining adequate fluid intake?aware of need for maintaining adequate fluid intake?
• If adequate fluid intake is difficult to maintain, have alternative treatment approaches been • If adequate fluid intake is difficult to maintain, have alternative treatment approaches been • If adequate fluid intake is difficult to maintain, have alternative treatment approaches been • If adequate fluid intake is difficult to maintain, have alternative treatment approaches been developed, attempt to increase fluid intake by the use of popsicles, gelatin, and other similar nondeveloped, attempt to increase fluid intake by the use of popsicles, gelatin, and other similar nondeveloped, attempt to increase fluid intake by the use of popsicles, gelatin, and other similar nondeveloped, attempt to increase fluid intake by the use of popsicles, gelatin, and other similar non----liquid foodsliquid foodsliquid foodsliquid foods????
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Dehydration Dehydration Dehydration Dehydration and Fluid and Fluid and Fluid and Fluid MaintenanceMaintenanceMaintenanceMaintenance
There is no There is no There is no There is no universally accepted definition of dehydration universally accepted definition of dehydration universally accepted definition of dehydration universally accepted definition of dehydration
SSSSeveral everal everal everal parameters parameters parameters parameters used used used used to suspect or define this to suspect or define this to suspect or define this to suspect or define this condition have condition have condition have condition have limitations. limitations. limitations. limitations.
CCCConfusion onfusion onfusion onfusion over the definition of dehydration results in confusion about the clinical over the definition of dehydration results in confusion about the clinical over the definition of dehydration results in confusion about the clinical over the definition of dehydration results in confusion about the clinical
diagnosis of dehydration in the longdiagnosis of dehydration in the longdiagnosis of dehydration in the longdiagnosis of dehydration in the long----term care (LTC) setting. term care (LTC) setting. term care (LTC) setting. term care (LTC) setting.
Dehydration Dehydration Dehydration Dehydration may be inappropriately used as a nonspecific generic term referring to may be inappropriately used as a nonspecific generic term referring to may be inappropriately used as a nonspecific generic term referring to may be inappropriately used as a nonspecific generic term referring to
derangement in any fluid compartment. Practitioners often use the term dehydration derangement in any fluid compartment. Practitioners often use the term dehydration derangement in any fluid compartment. Practitioners often use the term dehydration derangement in any fluid compartment. Practitioners often use the term dehydration
when they mean intravascular volume depletion. when they mean intravascular volume depletion. when they mean intravascular volume depletion. when they mean intravascular volume depletion.
FurthermoreFurthermoreFurthermoreFurthermore, a diagnosis of dehydration may be inappropriately used as a medical , a diagnosis of dehydration may be inappropriately used as a medical , a diagnosis of dehydration may be inappropriately used as a medical , a diagnosis of dehydration may be inappropriately used as a medical
reason for hospitalization when the diagnosis has resulted primarily from social reason for hospitalization when the diagnosis has resulted primarily from social reason for hospitalization when the diagnosis has resulted primarily from social reason for hospitalization when the diagnosis has resulted primarily from social
considerations. considerations. considerations. considerations.
At At At At hospital admission, many older people who are diagnosed as dehydrated do not meet hospital admission, many older people who are diagnosed as dehydrated do not meet hospital admission, many older people who are diagnosed as dehydrated do not meet hospital admission, many older people who are diagnosed as dehydrated do not meet
any accepted diagnostic criteria.any accepted diagnostic criteria.any accepted diagnostic criteria.any accepted diagnostic criteria.
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CONFUSION OVER DEHYDRATION DEFINITIONWWW.AMDA.COM
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Dehydration Dehydration Dehydration Dehydration refers to a complex condition refers to a complex condition refers to a complex condition refers to a complex condition
resulting in a loss of total body waterresulting in a loss of total body waterresulting in a loss of total body waterresulting in a loss of total body water————with or with or with or with or
without saltwithout saltwithout saltwithout salt————at a rate greater than the body at a rate greater than the body at a rate greater than the body at a rate greater than the body
can replace it. Dehydration is one form of can replace it. Dehydration is one form of can replace it. Dehydration is one form of can replace it. Dehydration is one form of
fluid/electrolyte imbalance. fluid/electrolyte imbalance. fluid/electrolyte imbalance. fluid/electrolyte imbalance.
A A A A fluid/electrolyte imbalance is defined as an fluid/electrolyte imbalance is defined as an fluid/electrolyte imbalance is defined as an fluid/electrolyte imbalance is defined as an
insufficiency or excess of either water or insufficiency or excess of either water or insufficiency or excess of either water or insufficiency or excess of either water or
electrolytes (sodium and potassium) in certain electrolytes (sodium and potassium) in certain electrolytes (sodium and potassium) in certain electrolytes (sodium and potassium) in certain
body body body body areas.areas.areas.areas.
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Dehydration and Fluid Maintenance clinical practice guideline
www.amda.com
WHY FOCUS ON NUTRITION?
Malnutrition is a major contributor Malnutrition is a major contributor Malnutrition is a major contributor Malnutrition is a major contributor to: to: to: to:
• increased morbidity and mortality,
• decreased function and quality of life,
• increased frequency and length of
hospital stay, and
• higher health care costs.
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•Federal
•State
•Professional
Organizations
•Identify the Team
•Team
Responsibilites
•Staff/Residents/
Families
•Programs
•Policies/Procedures
• Training/Education
• QI/QAPI Customers
•Vendors/Contracts
I. Know what I. Know what I. Know what I. Know what
”Best Practice” ”Best Practice” ”Best Practice” ”Best Practice”
Is for LTCIs for LTCIs for LTCIs for LTC
II. Facility II. Facility II. Facility II. Facility
Team Team Team Team
ManagementManagementManagementManagement
III. Facility III. Facility III. Facility III. Facility
Systems and Systems and Systems and Systems and
ProcessesProcessesProcessesProcesses
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