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Risk Management » Practice Tips
October 2006
Nutritional Well-being Promotes Quality of Life
In March of 1999, the Department of Health & Human Services, Office of Inspector General, Long Term Care Ombudsman Program released an executive summary of the complaint trends in nursing homes. The report indicated nursing home complaints are on the rise.
Complaints were categorized into five categories: resident care; resident rights; quality of life; facility administration; and not facility related. Of the five categories, resident care showed the greatest increase in complaints. This category included two examples of care complaints that increased dramatically. The increases included a 24% rise in complaints about weight loss due to inadequate nutrition and a 26% rise in hydration complaints.
Nutrition and hydration are components of care which represent basic human needs. Therefore, HCFA launched a campaign to educate consumers and nursing home staff about the risks of malnutrition and dehydration and nursing home residents’ rights. The Agency for Health Care Policy and Research cites evidence that correlates nutritional status with the prevention and treatment of pressure ulcers. According to the American Dietetic Association, malnutrition affects two of every five elderly nursing home residents. It is well accepted that a poor nutritional status, at least as defined by commonly used physiological parameters, is consistently associated with the risk of future complications. HCFA’s On-Line Survey, Certification and Reporting (OSCAR) 1999, listed the most frequently cited deficiency as the proper treatment to prevent/heal pressure ulcers. In December 2004 the percent of patients reported with pressure ulcers had continued to rise to a high of 8.7 percent. The professional liability industry claims data for long term care facilities reveals pressure ulcers have maintained a position of serious concern.
In 2004, the Centers for Medicare and Medicaid Services (CMS), formerly HCFA, implemented new OBRA survey standards and guidelines. The major substantive changes were to F314 and 483.25 regarding pressure ulcers. This change has expanded the length of the guidance to surveyors from three pages to thirty-seven pages and includes a comprehensive review of pressure ulcers based on best practices. The best practices parallel those outlined in the Council’s Pressure Ulcer protocol of May 2001. The survey process reviews pressure ulcer prevention, assessment, intervention and monitoring.
Civil suits due to falls are common in the industry, and nutrition and hydration may be implicated. Weakness, muscle wasting, decreased functional status and postprandial hypotension, all signs of poor nutritional status, are likely contributors to patient falls.
Advancing age, disease processes and staffing patterns can be just a few of the many reasons malnutrition can be present in the nursing home population. Many older adults may enter your facilities malnourished or at risk of malnutrition. The aging process, anorexia, inadequate food intake, social isolation, depression, dependency, functional disability, oral health and swallowing problems are among the many contributing factors to this problem. Unless ethical considerations call for an alternative approach, we must become more aggressive in recognizing, preventing and treating malnutrition in nursing home patients. This does present a challenge. The American Dietetic Association makes the following observations relative to addressing the problem of malnutrition in nursing homes:
- Sufficient time is needed in nursing homes to assess and monitor nutritional status and meal times.
- Registered dietitians, a part of an interdisciplinary team, have the training and expertise to address the nutritional well being of nursing home residents.
- Support proposals to allow facilities the ability to train a broader range of staff and volunteers to assist in feeding residents.
- Many successful long term care facilities have developed creative methods for residents (i.e., finger foods vs. 3 meals/day) to encourage food consumption and improve the eating environment to address social, emotional, physical and other concerns.
CMS has posted an approved repository of innovative ideas as part of its Sharing Innovations in Quality (SIQ) which contains clinical guidelines for nutrition/hydration. Visit this site at http://siq.air.org Practice Guidelines and Tools are also located at the American Medical Director Association. Visit this site at www.amda.com. Low cost solutions are available which may even have the potential to lower overall costs while improving the quality of life of our nursing home residents.
Resources:
American Medical Directors Association www.amda.com
American Dietetic Association, www.eatright.org
Nursing Home News Nursing Home Care Improves in Many Areas, But Pressure Ulcers Rise, Says CMS. Dec 2004 www.bethjanicek.com/NurseHmFiles/
Nursing Home Quality Initiatives, CMS www.cms.hhs.gov/nursinghomequalityinits
Sharing Innovations in Quality, siq.air.org
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