Long-Term Care Survey Alert

Published on Fri Sep 26, 2008 PDF

This menu of strategies provides a good start for sidestepping F325 tags.

Revised F325 survey guidance, which went into effect Sept. 1, puts nutrition in the survey spotlight. And you can expect surveyors to focus hard on whether you're using the care planning process to prevent and address unintended weight loss. If your facility falls short in that area of care, it's wide open to F325 and related tags.

Key point: The survey guidance attempts to incorporate the American Dietetic Association's nutrition care process throughout, which involves nutrition assessment and nutrition diagnosis, intervention, monitoring and evaluation, says Becky Dorner, RD, LD, of Becky Dorner & Associates Inc. and Nutrition Consulting Services Inc. in Akron, OH.

Focus on Accurate Weights at Specified Intervals

Make sure to weigh residents as dictated by the revised guidance, which is weekly for four weeks after admission to establish a baseline. Then if the person isn't losing weight, perform the weight checks monthly after that, advises Annette Kobriger, RD, CD, MPH, MPA, president of Kobriger Presents Inc., a training and management consulting firm in Chilton, WI. "But the facility should also weigh the person when he has a significant change in status, a decrease in food intake that persists more than a week -- or when the resident has signs of altered fluid status or fluid and electrolyte imbalance."

Survey tips: Weigh the resident at the same time of day, wearing the same amount of clothing and on the same scales calibrated for accuracy, says Kobriger. Surveyors will also be looking to see if the facility has a policy for correcting inaccurate weights. "Sometimes you'll see weights recorded in nursing homes that are really off base but no one addresses them," Kobriger cautions.

Assess, Document Meal Intake Accurately

Monitoring and documenting residents' intake through observation provides a first-line defense for detecting people who aren't eating enough and may be at risk for shedding pounds without intervention. "The thinking now is that the only true measurement of nutritional status for elderly people is how much they eat at meals," says Kobriger.

Tip: Include the resident's nourishment intake during activities, which can add up, advises Reta Underwood, president of Consultants for Long Term Care in Buckner, KY. She notes that most activities include a beverage and often a snack.

Resource: For information on how to use a research-validated dining observation tool for double checking the accuracy of meal intake documentation, see MDS Alert, Vol. 6, No. 9, p. 106.

Get the Team on the Case Fast

Under the revised guidance, expect surveyors to look at whether the interdisciplinary team is involved in addressing unintended weight loss or a persistent decrease in food intake. Surveyors will be looking for more input from the physician and nursing, Kobriger says. They will also be looking for rehab therapy input in terms of a focus on residents' functional status and its impact on their ability to eat, she counsels.

"The team will have to identify the true problems affecting a resident's nutrition," Kobriger stresses. She notes that the reasons elderly people don't eat range from oral health problems to numerous gastrointestinal problems, impaired ADLs, difficulty communicating food preferences, medical problems, behavioral issues, swallowing problems, etc. "The list is long. That's why evaluating poor intake or weight loss requires the whole team to look at different issues," Kobriger says.

Also review a resident's medications and their impact on the person's appetite or nutritional status, advises Kobriger. (For a list of routine meds that can suppress appetite, see Long-Term Care Survey Alert, Vol. 10, No. 4, page 30.)

Keep in mind: When a resident loses weight unintentionally, the surveyors will evaluate whether the weight loss was avoidable or unavoidable and the documentation to that effect, stresses Kobriger. They will also check to see if the team acted quickly to assess and address the resident's nutritional issues.

Don't stop short: Make sure to complete the care plan loop, Dorner advises. She notes that nursing facilities are often good at doing the initial assessment and implementing interventions, but they do not always do a good job of monitoring and evaluation -- and adjusting interventions to assure positive outcomes.

Also: Monitor residents choosing their own meals during buffet dining to ensure they are selecting healthy meals, Dorner advises. If they aren't, counsel or educate them about choosing a more balanced, healthy meal -- and document that you did, she adds.

Survey tip: Review the list of definitions in the survey guidance to ensure your team is speaking the same language as surveyors, advises Brenda Richardson, MA, RD, LD, a nutrition expert in Pekin, IN. For example, the guidance defines avoidable and unavoidable failure to maintain acceptable parameters of nutrition. And it defines dietary supplements and nutritional supplements, among other key terms.

Editor's note: Review the F325 guidance at www.cms.hhs.gov/transmittals/downloads/R36SOMA.pdf.