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YOUEAT IT FIRST!INTEGRATINGPERSONALCHOICE INTODININGSTANDARDSYOU EAT IT FIRST!INTEGRATINGPERSONALCHOICE INTODININGSTANDARDS

LIBBY YOUSEADMINISTRATIVE COACH FOR QIPMO660/651‐[email protected],LD,RD,StateSurveyor,andWendyBoren,BS,RN,QIPMONurseConsultant

OBJECTIVES

Understandtheimportanceoffoodpresentationandthediningexperience. Weuseallofoursenseswhenweeat.Thearoma,appearance,colorandtextureoffoodallplayapartinhowmuchoneeats,asdoes,theenvironment,thoseweeatwithandthosewhoserveorhelpuswithourmeals.F804directlyaddressespalatability,attractivenessandtemperatureoffoodsserved.

Understandtheregulationsregardingthe2011diningstandardsanddietconsistency.

Exploretheideaofrealfoodfirstversusvitamins.

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20QUESTIONS,THE FOODIEWAY!

It’sallaboutindividuality!– Whattimedoyouliketoeat?– Whatisyourfavoritesaladdressing?– Ketchuponeggs?Yayornay?– Whatdoyoulikeonyourpizza?– Areyoua“salter?”– Spiceornospice?– Whatisyourfavoritesummertimefood?– Whatwouldyouconsideryourcomfortfood?– Howhotdoyoulikeyourcoffee?– CokeorPepsi?

WHAT’S YOURWAY?

PlasticversuspaperversuschinaversusCorelle.– It’sbeenmyexperiencethatmostpeopleprefertouseregulardishesandcups.Theytendtoseepaperandplasticwareassomethingtouseatapicnicorbbq orwhensomeonedoesn’twanttododishes.Ifsomeonehastremors,theymayneedamoresubstantialcuporutensils.Mostpeopletendtodobetterwithmoderateweightserviceanddishes.Ifit’stooheavy,theymightnotbeabletouseit.Preferencesandneedsshouldbeassessed.F804addressesdignityandappropriatenessofdiningfacilitiesandservice.

Thetableclothcontroversy Passthegravyplease…ornot Fishday

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CHOICE

Howmanyforksdoesapersonneed?

NOTWOTASTEBUDSAREALIKE

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NEW(ER)DINING STANDARDS

AmericanAssociationforLongTermCareNursing AcademyofNutritionandDietetics AmericanMedicalDirectorsAssociation DietaryManagersAssociation Gerontological AdvancedPracticeNursesAssociation HartfordInstituteforGeriatricNursing NationalAssociationofDirectorsofNursingAdministrationinLong‐termCare

NationalGerontological NursingAssociation AmericanAssociationofNursingAssessmentCoordination

Createdin2011byacollaborationofthePioneerNetworkandtheRothchild Foundationwithcontributionsfrom

NEWDININGPRACTICE STANDARDS

RealFoodFirst Liberalization:Diabetic,Low‐sodium,Cardiac AlteredConsistencyDiets HonoringChoice ShiftingTraditionalProfessionalControltoSupportSelf‐DirectedLiving

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DINING –FIRST FULLMEAL

・ Dining – observe first full meal・ Cover all dining rooms and room trays・ Observe enough to adequately identify concerns・ If feasible, observe initial pool residents with weight loss・ If concerns identified, observe another meal

Dining– observefirstfullmeal Coveralldiningroomsandroomtrays Observeenoughtoadequatelyidentifyconcerns

Iffeasible,observeinitialpoolresidentswithweightloss

Ifconcernsidentified,observeanothermeal

DINING – SUBSEQUENTMEAL IFNEEDED

Secondmealobservedifconcernsnoted UseAppendixPPandCEPathwayforDining

Diningtaskiscompletedoutsideanyresidentspecificinvestigationintonutritionand/orweightloss

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CRITICAL ELEMENTPATHWAYDINING

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IMPORTANTMEETING

ResidentCouncil ListentoResidents Whatistheirchoice Whataretheysaying? toohot…toocold…notenough…requestofsomethingspecial…

University of Missouri, Sinclair School of Nursing

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WHYPRESENTATIONMATTERS

VS

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University of Mi 21

MEDICALIZEDDIETS ANDFOLLOW‐THROUGH

Continuousmonitoringandassessment.Nutritionalassessmentsshouldbecompletedwithachangeinnutritionalstatus,including,decreasedorincreasedintake,weightlossorgainandchangesinmedicalstatus.

Whenpotentialinterventionshavetheabilitytobothhelpandharm…theinterventionsshouldbereviewedbythedietitianinaholisticfashionanddiscussedwiththeresidentand/ortheirfamily/POAprior totheirimplementation.

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DIETLIBERALIZATION

Problem

Weightlossduetounappetizingtherapeuticdiets

Change

Minimizingortakingoutlow‐salt,low‐fat,andsugar‐restricteddiets.

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DIETLIBERALIZATION

Dietitians,physicians,nursingstaffandtherapistmustallbeopenmindedaboutliberalizationofdiets.Inacutesituations,arestrictivedietmaybemedicallynecessary.However,whenadietaryrestrictionslimitstheamountoffood,varietyoffoodandfrequencyofmeals,theconsequencesofthedietmayoutweighthebenefits.EachindividualshouldbeassessedbytheRDtodetermineifthebenefitsofthedietoutweightherisk.Also,theRDshoulddeterminetheresident’spreference.

University of Miss 24

F‐TAG692–AVOIDABLE VSUNAVOIDABLEWEIGHTLOSS

Nospecificdiagnosis“qualifies”asbeingassociatedwithunavoidableweightloss.

AvoidablemeanstheresidentdidnotmaintainacceptableparametersofnutritionalstatusandthefacilitydidNOTevaluatetheclinicalconditionandnutritionalriskfactors;identifyandimplementinterventionsconsistedwithneeds,goalsandstandardsofpractice;monitorandevaluatetheimpactoftheinterventions;and/orrevisetheinterventionsasneed.Thisincludessignificantandinsidiousweightloss.

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WEIGHTLOSS

Weightlossmaybebeneficialforoptimalhealth.TheresidentmustbeassessedbytheRDforappropriatenessandeducatedonweightlossinterventions.Iftheresidentisagreeable,goalsshouldbeclearlyidentifiedandprogressshouldbemonitored.

University of M 26

WEIGHT LOSSAS PARTOFTHE

DISEASEPROCESS

Decreasedappetiteandalteredhydrationsarecommonattheendoflife.Oftenappetiteandtheabilitytodigestfoodisdecreasedwhichcontributestoweightloss.

Offerfrequentsmallmealswithpreferencesandtoleranceinmind.

Offerfrequentdrinksoftoleratedfluids.

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F‐TAG636–ASSESSMENT

Anutritionalassessmentshouldincludeinformationabouttheresident’sappearance;height;weight(includingweighthistory);foodandfluidintake;alterednutrientintake,absorptionandutilization;chewingandswallowingabnormalities;functionalability;medication;laboratoryanddiagnosticdata;wounds;goalsandprognosis;andevenenvironmentalfactorswhichmayalterintake.

TheRDshouldmakenutritionalrecommendationsbaseduponthenutritionalassessmentbesuretoclearlyidentifyfindingsandplan.

Aplanofcareshouldbedevelopedbasedonthenutritionalassessment.

TheRDshouldeducatedtheresidentandfamilyasappropriate.

REMEMBER,theresidenthastherighttomakeinformedchoicesaboutacceptingordecliningcareandtreatment.

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F‐TAG692‐ NUTRITION,DEFICIENCYQUALITY CARETAG

SeverityLevel4‐ImmediateJeopardy:Substantialandongoingdeclineinfoodintakeresultinginsignificantunplannedweightlossduetodietaryrestrictionsordowngradeddiettextures(e.g.,mechanicsoft,pureed)providedbythefacilityagainsttheresident’sexpressedpreferences.

SeverityLevel3‐ActualHarm:Unplannedweightchangeanddecliningfoodand/orfluidintakeduetothefacility’sfailuretoassesstherelativebenefitsandrisksofrestrictingordowngradingdietandfoodconsistency

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STAFFING F801

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who—(i) For designations prior to November 28, 2016, meets the following requirements no

later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate’s or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and

(ii) (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and

(iii) (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

STAFFING F801GUIDANCE§483.60(A)(1)‐(2)

Cite F801 for concerns regarding the qualifications of the dietitian, other clinical nutrition professionals, or the food services director.

In addition, cite F801 if staff, specifically the qualified dietitian or other clinically qualified nutrition professional did not carry out the functions of the food and nutrition services. While these functions may be defined by facility management, at a minimum they should include, but are not limited to:

• Assessing the nutritional needs of residents; • Developing and evaluating regular and therapeutic diets, including texture of foods and liquids, to meet the specialized needs of residents; • Developing and implementing person centered education programs involving food and nutrition services for all facility staff; • Overseeing the budget and purchasing of food and supplies, and food preparation, service and storage; and, • Participating in the quality assurance and performance improvement (QAPI), as described in §483.75, when food and nutrition services are involved.

The qualified dietitian or other clinically qualified nutrition professional can decide to oversee and delegate some of the activities listed above to the director of food and nutrition services.

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QUESTIONS SURVEYORSMAYASK

If the practices of the dietitian, nutrition professional, and/or food services director contributed to the identified concerns. If so how?

• How facility management ensures that staff have the appropriate competencies and skills sets to carry out the functions of the food and nutrition service? • If a food services director is employed by the facility, do they have frequent consultations with the dietitian or other nutrition professionals or consultants employed by the facility? POTENTIAL RELATED TAGS• §483.25(b)(1), F686, Pressure Injury o Determine if the facility identified, evaluated, and responded to a change in a resident’s skin integrity.

• §§483.25(g)(1)-(3), F692, Nutrition/Hydration Status o Determine if the facility identified, evaluated, and responded to a change in nutritional parameters, anorexia, or unplanned weight loss, dysphagia, and/or swallowing disorders in relation to the resident’s ability to eat.

• §§483.25(g)(4)-(5), F693, Tube Feeding Management o Determine if the facility identified, evaluated, and responded to the use of a nasogastric and gastrostomy tubes.

University of Missou 32

RECOMMENDATIONS

Dietshouldbedeterminedbytheperson,nottheexclusivelythediagnosis.

Althoughapersonmaynotbeabletomakedecisionsaboutcertainaspectsoftheirlife,thatdoesnotmeantheycannotmakechoicesindining.Alldecisionsdefaulttotheperson.

Failureisimminentwhenothersmakedecisionsaboutyourfood.

Assesstheperson’spreferredcontextandenvironmentformeals…routines,physicalsupport,abilitytouseadaptedeatingutensils,timingofmeals.– AreYOUabreakfasteater?– WhatareYOURroutines?

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YOUEAT IT FIRST!

University of M 34

REALFOODFIRST! AMDA—providefoodsofaconsistencyandtexture

thatallowforcomfortablechewingandswallowing.Aresidentwhohasdifficultyswallowingmayrejectpureedorartificiallythickenedfoodsbutmayeatfoodsthatarenaturallyofapureedconsistencylikemashedpotatoes,puddings,yogurt,andfinelychoppedmayretaintheirflavorandbeequallywell‐handled.

CMS—withanynutritionprogram,improvingintakeviawholesomefoodsisgenerallypreferabletoaddingnutritionalsupplements.

*Oralsupplementsoftengetwasted!

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REALFOODFIRST!

Consideradditionalsmallmealssuchascottagecheeseandfruit,½asandwich,cerealandwholemilk,icecream,milkshakesandpuddingmadewithwholemilkinplaceofpreparedoralsupplements.

University of Missou 36

IN THEWORDSOFMARIEANTOINETTE…“LET THEMEAT CAKE!”

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UMO 2016 37

WASTEBY THENUMBERS

Ifyouhave159beds,then:1.8lbs/bed/day*159beds=286lbs/day286lbs/day*7days/week=2,002lbs/week=1tonoffoodwasteperweek

Source:RecyclingWorks,Massachusetts


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DIETARYGUIDELINES2015‐2020

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FOODSAFETY

F812 Procurefoodfromsourcesapprovedorconsideredsatisfactorybyfederal,state,orlocalauthorities.

Mayincludefooditemsobtaineddirectlyfromlocalproducers,subjecttoapplicableStateandlocallawsorregulations.

Doesnotprohibitorpreventfacilitiesfromusingproducegrownandfoodhandlingpractices.

Doesnotprecluderesidentsfromconsumingfoodsnotprocuredbythefacility.

University 40

REALFOODFIRST

Growyourowngarden,withtheresidentshelp!

Supplementcalorieswithrealicecreamorfruitsorveggiespackedfullofvitaminsandminerals

Toincreasenutrientintake,foodscanbefortifiedwithheavycream,butter,gravies,saucesanddehydratedmilk.

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FOODSTORAGE

RefrigeratorandFreezersatappropriatetemperatures

Freezer– Atorbelow0 Allfoods– labeled,dated,andshelved(4”offfloor)

Cookedfoodsstoredaboverawmeatandeggs/eggrichfood.Datewhentakenoutoffreezer.

FOODSTORAGE

Drystorage Evidenceofrodentsorpests. Isfoodcovered?Arelidsclosedandsealed?Arefoodcontainersingoodcondition?Dents?Evidenceofdamagetopackaging?Andoffthefloor?

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FOODSAFETY ‐SANITATION

Hotfoodsmaintainedattheappropriatetemperature Coldfoodsmaintainedattheappropriate

temperature Conditionofdinnerwareandutensils Foodscovereduntilserved Foodprotectedfromcontaminationduring

transportationanddistribution Employeehandwashing(beforeandafterhandling

food) Prepstaffusingcleanutensilswhennecessaryand

followinfectioncontrolpractices.

FOODSAFETY ‐SANITATION

Kitchen– pests,mice,cockroachesandyesMissouriFlies.

Trashcanscovered Door’sproppedopen SanitizingBuckets&rags SanitizingSink Underthedishwasher?????

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FOODSAFETY

HoldingTemps Steamtables=135degreesF Roomtrays=120degreesF Protectfoodwhentransporting

SURVEY&INSPECTION

TempsonAutomaticDishwasher(log) 120degreeswash&140degreesrinse DishwareDrying– selfdrainingposition

Staffinterviews– Howhaveyoubeentrained.

Recordreview– Menus

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CRITICAL ELEMENT:KITCHENCRITICAL ELEMENT:KITCHEN

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SURVEY

Weight– Arethereidentifiedproblemswithresidentsweight(GainorLoss)

Complaints– toomuchchicken(theywilllookatyourmenus)

Toohot– toocold(checkfoodtemps) Theyaregoingtoaskresidentiftheircomplaintwasaddressed.

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LOW‐SODIUMDIETS

AND—recommends DASH (Dietary Approaches to Stop Hypertension)…reduces blood pressure, may reduce rates of heart failure…use DASH menu to help achieve these goals

NEWS FLASH: the typical 2 gram sodium diet recommended for people with hypertension has been shown to reduce systolic blood pressure on average by only 5mmHg and diastolic blood pressures by only 2.5mmHg.


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2GRAMSODIUMRESTRICTEDDIETS

Specificfoodsmayberequiredtobepurchasedandprepared.

Ifoneresidenthasanorderforasodiumrestricteddiet,rememberthatotherscanhavesaltandpreparetheirmealsaccordingly.

Foodslowinsodiumoftenlacktheflavortowhichresidentsareaccustomedandmynotbeacceptedwhichcouldcontributetodecreasedintake,nutrientdeficitsandweightloss.

Oftenjustencouragingavoidanceofthesaltshakercansignificantlylowersodiumintake.

Ifa2gramsodiumrestricteddietisordered,theRDshouldassesstheresidentforappropriatenessandacceptanceofthedietaryrestriction.

TheRDshouldeducatedtheresidentasappropriate.

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016 57

ALTEREDCONSISTENCYDIETS

#1REASONPRESCRIBED??...SwallowingdifficultiesNOTE:Dysphagiaisnotadiagnosis.Itisasymptomcommonlyassociatedwithconditionssuchasstroke,dementia,orParkinson’sdisease.

AMDA—Swallowingabnormalitiesarecommonbutdonotnecessarilyrequiremodifieddietandfluidtextures,especiallyiftheserestrictionsadverselyaffectfoodandfluidintake.

AND—Olderadultsconsumingmodifiedtexturedietsreportincreasedneedforassistancewitheating,dissatisfactionwithfoods,anddecreasedenjoymentofeating,resultinginreducedfoodintakeandweightloss.

University of Missour 58


CMS—takeaholisticapproach(NOTaone‐size‐fitsallidea)Alteredconsistencyshouldbeimplementedbasedonassessmentofneedandresidentacceptance.Theconsistencyneededshouldbeclearlyidentified.Somefoodsmaynotneedtobealtered.Also,thefoodshouldtastelikewhatitisonlythetextureshouldbealtered.Staffassistingwithdiningshouldbeawareofwhatallfooditemsareandshouldinformtheresident.Notallresidentswithdysphagiaaspirateorchokeandallaspirationresultsinpneumonia.X‐raysshouldnotbedoneroutinely.Consideriftheresidentexhibitssymptomsofaspirationpneumonia.Improvedoralcarecanreducetheriskofdevelopingaspirationpneumonia.

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Choiceandacceptanceofalteredconsistencycancontributetomalnutritionanddehydration.

Encourageproperpositioningandeating/drinkingtechniquesasappropriatetoreducetheriskofaspirationandpromoteintake.

Prepareandservefoodandbeveragesinaccordancewithassessedneeds,physician’sordersandtheresident’spreferences.

Allowadequatetimeandstaffassistancetopromoteintake.

Residentswhoexhibitproblemswithchewingand/orswallowingmaybeself‐consciousanddobetterinamoreprivatesettingwithappropriatestaffassistance.

UnivQIPMO 2016 60

ALTEREDCONSISTENCYDIETS…TUBEFEEDING

Shouldnotautomaticallybe“thenextstep”

Maycausediarrhea,abdominalpain,andmayincrease theriskofaspiration

Personaladage…whenenoughisenough…specialcircumstancesandlettinggo

Weighbenefitsvscomplications.Oftenresidentsandfamiliesarenotrealisticintheirexpectationsrelatedtotubefeedings.

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DIABETICDIETS

Diabetescangenerallybemanagedwithaconsistentcarbohydratedietsandmedicationadjustments.

Sugarfreeor“diet”foodscancontributetoelevatedglucoselevels.

TheresidentshouldbeassessedbytheRDwithgoalsandinterventionsidentified,implemented,monitoredandrevisedasneeded.

TheRDshouldprovideeducationasappropriatetotheresident.

JustreleasedFeb.2016fromAmericanDiabetesAssociation…Liberaldietplansarepreferabletotherapeuticdiets‐ morefoodchoicesbenefitnutritionalneedsandglycemiccontrol.

GO SIT IN YOURDININGROOM

Eatwitharesident Coughing Noise Service Positioning

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IS ITGOOD

YES– TASTETHEFOOD

QUESTIONS

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RESOURCES

http://www.forbes.com/sites/caroltice/2014/08/14/7‐fast‐food‐restaurantchains‐that‐rake‐in‐2m‐per‐store/#3fdbe970ce5a

http://www.restaurant.org/Downloads/PDFs/State‐Statistics/2016/MO_Restaurants2016

http://recyclingworksma.com/food‐waste‐estimation‐guide/#Jump05

https://pioneernetwork.net/Providers/DiningPracticeStandards/

https://health.gov/dietaryguidelines/2015/guidelines

you eat itfirst - nursing home help | sponsored by ... · – what time do you like to eat? ... not...

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