Weight loss prevention strategies: what is your facility's score? preventing unintended weight loss in residents requires a multidisciplinary approach - Feature Article

Nursing Homes, June, 2003 by Annette M. Kobriger

Preventing weight loss and malnutrition--and the occurrence of pressure ulcers that these can contribute to--is a hot topic for long-term care facilities. As a result, survey citations, civil lawsuits, and Medicare fraud prosecutions related to nutrition have become routine risk-management issues. Facilities across the country, however, have implemented successful strategies for managing nutrition, and we have incorporated their "best practices" into a scorecard (Figure). Although this scorecard has not been scientifically tested, facilities might find it useful in assessing and improving their nutritional programs, as well as giving them new ideas.

Managing nutrition requires a multidisciplinary approach, involving administration, the rehab/therapy-departments, the nutrition professional, nursing, and the medical director. This article will highlight some of the nutritional best practices as they relate to each of these key players on the facility "nutrition team."

"Nutrition Team" Members' Roles

Administration. The facility administrator has an important leadership role in the caregiver team. By being present in the dining room at least once weekly, he or she demonstrates to other staff members that mealtime is an important activity. Regular visits by the administrator also have a positive effect on resident satisfaction and families' initial impressions when touring the facility.

In addition, these routine visits are important because the dining room is one of a facility's major cost centers. The hours spent there by certified nursing assistants (CNAs) alone, especially on the day shift, represent a significant cost. Add to that the wages of the dietary staff, costs of food, and supplement expenses, and it becomes obvious that the dining room deserves and requires the administrator's attention.

The administrator must make it a point to know who's in charge of the dining room. This would seem obvious, but although in some facilities it is supervised by the dietary director and in others by the assistant director of nursing, the dining room often has no particular staff person in charge. For all practical purposes, this means that the employees working there determine the rules-- certainly not an advisable way for a business to operate one of its major cost centers. Each facility needs to decide who would be the best person to oversee its dining room, but someone definitely should be in charge.

One method to help administration stay on top of important issues in the dining room is to use a checklist that includes issues surveyors look for there. Daily checking ensures that potential or existing problems are addressed in a timely manner. Issues to consider in the dining room are:

* availability of adaptive equipment;

* correct diets for residents;

* correct food/fluid textures; and

* availability of substitutes for residents not eating planned menu items.

Using a checklist and having a specific person in charge of the dining room will help ensure that dining needs--such as food dislikes, a decline in a resident's ability to feed him/herself, or behavior problems--are being communicated to the appropriate staff member who can help.

Rehab/therapy departments. A rehabilitation dining program is an important resource for residents with declining self-feeding skills. By being present regularly in the dining room, occupational-and speech-therapy staff can screen for eating, swallowing, and positioning difficulties. This can help maintain and prevent declines in residents' ability to feed themselves. In addition to maintaining the best quality of life possible for residents, identifying their needs in these areas can lead to additional Medicare Part B therapy referrals, as well.

Nutrition professionals. The registered dietitian, who generally serves the facility on a consultant basis, and the facility's dietary department form a vital component of the team that oversees nutrition. The administrator usually decides how many hours each week the facility needs a consultant dietitian. A minimum of eight hours weekly for every 100 residents is generally recommended. Allowing adequate time for consultation is essential to positive outcomes. It is also recommended that the consultant dietitian communicate with both the DON and the food-service director during each consultation visit. It should go without saying that to benefit from the consultant dietitian's recommendations, the facility must implement them.

The dietary department plays a critical role in meeting residents' needs for food and fluids. The dietary staff needs to make critical information regarding residents' nutritional needs and problems available to the consultant dietitian.

One area of concern for nutrition professionals is residents' end-of-life wishes regarding nutrition and hydration. When residents are first admitted, it is important to determine whether they have completed advance directives regarding these issues, which specify the nutritional support they want or don't want to receive if they later become unable to make their own medical decisions. Determining this at admission provides an opportunity for the resident and family to discuss the resident's future wishes if advanced directives have not already been completed prior to admission. Making the best decisions for residents regarding such weighty matters requires presence of mind; therefore, the best time to discuss them is at admission, not after the resident already has begun to lose weight or has trouble eating.