Nutrition and Hydration - F 692 - Re-Ignite Your Spark 9/24/2021 - Kansas ...
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9/24/2021
Nutrition and Hydration
F 692
Re-Ignite Your Spark
1
9/24/2021
Re-Ignite Your Spark
F 692 Current Regulatory Trends
Data collected by LICA-MedMan and KHCA
(September 2021):
Region VII CMS Survey Region (Iowa, Kansas,
Missouri and Nebraska)
F 692 is not in the top 10 frequently cited
deficiencies
F 692 is in the top 10 frequently cited
deficiencies resulting in a G Level deficiency
(#6) with 19 Citations and (#15) resulting in
an IJ with 2 Citations
2
9/24/2021
Intent of Regulation
The intent of this requirement is that the resident
maintains, to the extent possible, acceptable
parameters of nutritional and hydration status
and that the facility:
◦ Provides nutritional and hydration care and services
to each resident, consistent with the resident’s
comprehensive assessment;
◦ Recognizes, evaluates, and addresses the needs of
every resident, including but not limited to, the
resident at risk or already experiencing impaired
nutrition and hydration; and
◦ Provides a therapeutic diet that takes into account
the resident’s clinical condition, and preferences, when
there is a nutritional indication.
Definitions
“Acceptable parameters of nutritional
status” refers to factors that reflect that
an individual’s nutritional status is
adequate, relative to his/her overall
condition and prognosis, such as weight,
food/fluid intake and pertinent laboratory
values.
3
9/24/2021
Definitions
“Artificial nutrition and hydration” are
medical treatments and refer to nutrition
that is provided through routes other
than the usual oral route, typically by
placing a tube directly into the stomach,
the intestine or a vein.
“Tube feeding” refers to the delivery of
nutrients through a feeding tube directly
into the stomach, duodenum, or jejunum.
It is also referred to as an enteral feeding.
Definitions
“Clinically significant” refers to the effects,
results, or consequences that materially
affect or are likely to affect an individual’s
physical, mental, or psychosocial well-
being either positively by preventing,
stabilizing, or improving a condition or
reducing a risk, or negatively by
exacerbating, causing, or contributing to a
symptom, illness, or decline in status.
4
9/24/2021
Definitions
“Dietary supplements” refers to herbal and
alternative products that are not regulated
by the FDA and their composition is not
standardized. Dietary supplements must be
labeled as such and must not be represented
for use as a conventional food or as the sole
item of a meal or the diet.
“Nutritional supplements” refers to
products that are used to complement a
resident’s dietary needs (calorie or nutrient
dense drinks, TPN, enteral products and
meal replacement products).
Definitions
“Therapeutic diet” refers to a diet
ordered by a physician or other delegated
provider that is part of the treatment for
a disease or clinical condition, to
eliminate, decrease, or increase certain
substances in the diet (sodium or
potassium), or to provide mechanically
altered food when indicated.
59/24/2021
Certified Dietary Manager
F 801
Educational Requirements
◦ Graduation from an AFNP-approved dietary
training program
◦ Associate’s or Bachelor’s degree in Foodservice
Management or Nutrition, culinary arts or hotel-
restaurant management
◦ 2 years of institutional foodservice management
and complete an approved 90 hour foodservice
course
◦ Current or former member of the U.S. military
with the pay grade of at least E-5 and have
graduated from an approved military dietary
manager training program
Registered Dietitian
(R.D. or R.D.N.)
Minimum of a Bachelor’s Degree
accredited by the ACEND
1,200 hours in a supervised internship
CDR Exam
By 2024, a graduate degree will be the
minimum requirement to sit for the CDR
exam
69/24/2021
Nutritionist
The role of the dietitian is more regulated
and the titles should not be used
interchangeably.
Anyone who completes a degree in
nutrition can refer to themselves as a
nutritionist.
Significant difference is that the dietitian
can help diagnose and treat illness
(Medical Nutrition Therapy)
Guidance
Important to maintain adequate nutritional status, to
the extent possible, to ensure each resident is able to
maintain the highest practicable level of well-being.
Early identification of residents with, or at risk for,
impaired nutrition or hydration status may allow the
IDT to develop and implement interventions to
stablize or improve nutritional status before
complications arise.
◦ Weight and lab results can be stabilized or improved, but
not be correctable in some individuals
◦ Intake alone is not the only factor that can affect
nutritional status
◦ Resident conditions and co-morbidities may prevent
improved nutritional or hydration status, despite improved
intake.
79/24/2021
Guidance
Factors influencing weight and nutritional
status in aging:
◦ Body may not absorb or use nutrients
effectively
◦ Changes in the ability to taste
◦ Decreased sensation for thirst or hunger
◦ Medical condition(s) affecting weight
maintenance (muscle mass, cognitive status,
end of life, disease processes, fluid retention)
Guidance
Failure to identify residents at risk for
compromised nutrition and hydration may
be associated with an increased mortality
and other negative outcomes
◦ Impairment of Wound Healing
◦ Functional Decline
◦ Fluid and Electrolyte Balance and Dehydration
◦ Unplanned Weight Change
◦ Urinary Tract Infections, Pneumonia,
Confusion, Disorientation
89/24/2021
Guidance
Weight loss, poor nutritional status or
dehydration should be considered
avoidable unless the facility can prove it
has assessed/reassessed the resident’s
needs, consistently implemented related
care planned interventions, monitored for
effectiveness and ensured coordination of
care among the IDT.
Assessment
A comprehensive nutritional assessment
should be completed on any resident
identified as being at risk for unplanned
weight loss/gain and/or compromised
nutritional status.
The assessment may utilize existing
information from sources, such as the RAI,
assessments from other disciplines, the
existing medical record, observation, direct
care staff interviews and resident and family
interviews.
99/24/2021
Assessment
General Appearance
◦ Residents overall appearance (robust, think,
obese, muscle wasting) and may include
resident’s cognitive status, affect, oral health
and dentition, ability to use the hands and
arms and condition of hair, nails and skin
Height
◦ A protocol for determining height helps to
ensure that it will be measured as consistently
as possible.
Assessment
Weight
◦ Useful indicator when evaluated within the
context of the individual’s personal history and
overall condition. Weight goals should be based
on a residents usual body weight or desired body
weight.
◦ Procedure establishing a consistent method of
weighing (using the same scale, wearing the same
clothes, weight at the same time of day), verifying
the resident’s weight upon admission, monitoring
a resident’s weight over time to identify weight
loss/gain, verifying weight measurements when
changes occur and reassessment of interventions.
109/24/2021
Assessment
Standards of Practice
◦ Weight upon Admission or Readmission
◦ Weekly for the 1st Month
◦ Monthly Weight
Identification of “Slow and Progressive Weight Loss”
◦ Weighing may also be pertinent if there is a
significant change in condition, food intake has
declined and persisted (more than one week)
or evidence of altered nutritional status or
fluid and electrolyte imbalance.
Assessment
Weight Consideration
◦ Usual Body Weight, Medical Conditions, Diet and
Supplement Orders, Changes in PO intake and
Edema
Parameters
◦ Differentiate Significant and Severe Loss
5% or Greater than 5% in 30 Days
7.5% or Greater than 7.5% in 90 Days
10% or Greater than 10% in 180 Days
Formula:
% of Body Weight Loss = (usual weight-actual weight)/(usual
weight) x 100
119/24/2021
Assessment
Interviews with Key Staff Members
◦ Direct Care Staff (PO Intake)
◦ Physicians and Non-Physician Practitioners
(Relevant Diagnosis, Causes of Weight
Changes)
◦ Qualified Dietitians (Nutritional Risk Factors
and Nutritional Interventions)
◦ Pharmacists (Medication Interactions)
Assessment
Food and Fluid Intake
◦ Estimated Calorie, Nutrient and Fluid Needs
◦ PO intake to meet those needs (including by
mouth, enteral or parenteral)
◦ Meal and Snack patterns (time of supplement and
medication consumption), special food
formulation (ethnic and finger foods), dislikes and
preferences, preferred portion sizes
◦ There is no reliable calculation to determine an
individual’s fluid needs, an assessment should take
into account those characteristics pertinent to
the resident such as age, diagnoses and activity
level.
129/24/2021
Assessment
Fluid Loss or Retention
◦ Can cause short term weight change
◦ Decreased appetite = Fluid/Electrolyte
Imbalance
Abrupt weight changes, changes in PO intake or
altered level of consciousness
Lab Tests (BUN, creatinine and Serum Osmolality)
Assessment
Altered Nutrient Intake, Absorption and Utilization
◦ Congnitive or or functional decline
◦ Difficulty with chewing or swallowing food
◦ Inadequate amount of food or fluid, including insufficient tube
feedings
◦ Lack of adequate assistance or supervision
◦ Adverse consequences related to medications
◦ Diseases and conditions (cancer, diabetes, heart or lung disease,
infection and fever, liver disease, kidney disease, hyperthyroidism,
mood disorders, GI disorders, wounds, repetitive movement
disorders)
◦ Use of Diuretics may cause weight loss not associated with
nutritional issues. This may result in planned weight loss but can
also cause fluid and electrolyte imbalance/dehydration that
causes a loss of appetite and weight if unmonitored.
139/24/2021
Assessment
Laboratory/Diagnostic Evaluation
◦ Sometimes useful in identification of underlying
causes of impaired nutrition, when the clinical
assessment alone is not enough to define
nutritional status.
◦ Although lab tests such as albumin and pre-
albumin may help in some cases in deciding to
initiate nutritional interventions, there is no
evidence that they are useful for the serial follow-
up of undernourished individuals (low albumin
levels may be unrelated to nutrition, reflecting an
acute illness).
Should Albumin and Prealbumin be
used as Indicators for Malnutrition?
Question of the Month in 2017, published
in the Journal of the Academy of
Nutrition and Dietetics
◦ According to the Academy’s Evidence Analysis
Library, serum proteins such as albumin and
prealbumin are not included as defining
characteristics of malnutrition because
evidence analysis shows that serum levels of
these proteins do not change in response to
changes in nutrient intake.
149/24/2021
Care Planning
Information gathered from the nutritional assessment
and dietary standards of practice are used to develop
an individualized care plan to address the resident’s
specific nutritional concerns and preferences.
◦ The care plan must address, identified causes of impaired
nutritional status, resident’s personal goals and preferences
and resident specific interventions, including a time frame
and parameters for monitoring.
◦ The care plan should be updated as needed, when the
resident’s condition changes, goals are met, interventions
are determined to be ineffective or as new problems are
identified.
◦ If goals are not achieved, interventions must be
reevaluated for effectiveness and modified as appropriate.
Care Planning
There should be a documented clinical basis for any
conclusion that nutritional status or significant weight change
are unlikely to stabilize or improve (physician documentation
as to why the weight loss is medically unavoidable).
The resident and/or resident’s representative’s involvement
in the development of the care plan helps to ensure it is
individualized and meets their personal goals and
preferences.
Decisions related to the possible provision of supplemental
or artificial nutrition should be made in conjunction with the
resident, the resident’s family and/or representative in
accordance with state law, taking into account condition,
prognosis and the resident’s known values and choices.
159/24/2021
Interventions
Diet Liberalization
◦ It could be beneficial to minimize restrictions,
such as therapeutic or mechanically altered
diets.
It is the responsibility of the facility:
Talk with the resident, their family and representative and
provide information pertaining to the risks and benefits of a
liberalized diet
Work with the resident’s physician using the care planning
process
Accommodate the resident’s needs, preferences and goals.
Academy of Nutrition and Dietetics
Position Paper
October 2010
◦ Position of the American Dietetic Association:
Individualized Nutrition Approaches for Older
Adults in Health Care Communities
April 2018
◦ Position of the Academy of Nutrition and
Dietetics: Individualized Nutrition
Approaches for Older Adults: Long-Term
Care, Post-Acute Care and Other Settings
169/24/2021
Interventions
Weight-Related Interventions
◦ Involve the resident and/or the resident
representative to ensure the resident’s needs,
preferences and goals are accomodated
Interventions
Environmental Factors
◦ Appetite is often enhanced by the appealing
aroma, flavor, form and appearance of food.
◦ Pleasant dining experience may improve
intake
Flexible dining environments, styles and schedules
Providing meals that are palatable, attractive and
nutritious (food temperatures and seasonings)
Environment where residents eat is conducive to
dining (dining room and/or resident’s room)
179/24/2021
The Dining Room
“Meal Monitor Program” Implementation
Customer Satisfaction System or Process
Resident Council Involvement
Interventions
Disease Processes
◦ A resident’s clinical condition may have a
significant impact on the types of
interventions considered. The facility is
responsible for identifying relevant diagnosis
and appropriate interventions to address
specific needs, as applicable.
189/24/2021
Interventions
Functional Factors
◦ Conditions that interfere with the ability to
physically perform the task of eating or drinking
adequately, such as the ability to use one’s hands,
vision, chewing and swallowing capabilities or the
ability to reposition one’s self at the table.
Underlying causes should be assessed and identify
interventions which may be most effective (dentures)
Specialized dishes and utensils
Eye glasses and Hearing aids
Restorative eating programs
Direct Assistance by Staff
Food and Drinks are readily accessible and in close
proximity to individuals with mobility impairments
Interventions
Modification of food and fluid consistency
may be an appropriate intervention,
however it may unnecessarily decrease
the quality of life and impair nutritional
status by affecting appetite and reducing
intake.
199/24/2021
Interventions
Medications
◦ Help to increase appetite, reduce acid reflux,
reduce nausea
◦ Unintended effect of impairing a resident’s
nutritional or hydration status, experiencing a
lack of appetite, nausea, dry mouth or other
unintended effects.
A resident may require frequent sips of a drink
during a meal if they experience a dry mouth.
Interventions
Improving intake with wholesome foods is generally
preferable to adding nutritional supplements.
Supplements may be tried to increase calorie and
nutrient intake
Taking a nutritional supplement during medication
administration may also increase caloric intake
without reducing the resident’s appetite at mealtime.
◦ Fortification of Foods (added protein, fat and
carbohydrates)
◦ Smaller more frequent meals
◦ Between meal snacks or nourishments
◦ Increasing portion sizes of favorite foods
209/24/2021
Food First Approach
Fortified Foods – Items prepared in house
that provide additional calories and/or
protein and are not required to be ordered
by the physician
Snacks – Regular food items that are
available and generally are not required to
be ordered by the physician
Commercially Prepared Supplements are
discouraged at meal time. It is preferred to
use items from the menu and fortify or
enhance them to allow maximum meal time
intake.
Real Food Options
“Healthy versus Unhealthy”
◦ Ice Cream
½ cup = 220 calories and 3 g protein
◦ Chocolate Milk
8 oz = 220 calories and 8 g protein
◦ Whole Milk
8 oz = 150 calories and 8 g protein
◦ Peanut Butter
2 Tbsp = 190 calories and 7 g protein
1 Slice Wheat Bread = 110 Calories and 4 g protein
1 Tbsp Grape Jelly = 50 calories
◦ Egg
1 Large= 74 calories and 6 g protein
◦ Yogurt
4 oz = 90 calories and 3 g protein
8 oz = 180 calories and 6 g protein
219/24/2021
Fortified Foods
Enhanced in Calories and Protein
Minimum of 180-190 Calories
5-6 grams of Protein
Examples
◦ Cheesy Eggs
◦ Fortified Milk
◦ Power Potatoes
◦ Power Pudding
◦ Super Cereal
◦ Fortified Juice, Hot Cocoa, Soup
Supplement Formulary
Example: Abbott Nutrition or Nestle
2.0 Products
Popular: Butter Pecan or Vanilla (32 oz)
2 oz = 120 Calories, 5 g Protein
Usage: Consumption, Supplement appropriate with Medication Pass and Lactose
Intolerance
Hormel Health Labs
◦ Mighty Shakes
Chocolate, Strawberry or Vanilla (4 oz)
200 Calories, 6 g Protein
Usage: Malnutrition
No Sugar Added Version = 4 oz (200 Calories, 8 g Protein)
◦ Magic Cups
Popular: Orange or Berry Wild (4 oz)
290 Calories, 9 g Protein
Usage: Malnutrition, Texture Modified Diet Alternative (Frozen as Ice Cream or Thawed as
Pudding)
229/24/2021
Supplement Formulary
High Protein Powder(s)
◦ 1 Packet = 8 g Protein
◦ Usage: Powder Protein Supplement for Wound Healing, Malnutrition
Boost Breeze
◦ Popular: Wild Berry, Orange, Peach and Variety Pack
◦ 8 oz = 250 Calories, 9 g Protein
◦ Usage: Lactose Free and Gluten Free Supplement Option
Prostat
◦ SF Vanilla, SF Wild Cherry Pouch
◦ 30 ml = 60 Calories, 15 g Protein
◦ Usage: Liquid Protein Supplement that contains L-Tryptophan for Wound Healing, Malnutrition
Prostat AWC
◦ SF Wild Cherry
◦ 30 ml = 108 Calories, 17 g Protein
◦ Usage: Liquid Protein Supplement that contains L-Arginine, L-Cystine, Zinc and Vitamin C for Multiple Wounds, Stage 3 and 4 Pressure Ulcers
◦ *Short Term Use and Clinical Follow-Up for effectiveness recommended
Arginaid
◦ Orange, Cherry
◦ 1 Packet = 25 Calories, 0 g Protein
◦ Usage: Chronic and Advanced Wound Healing
◦ Supplement that contains L-Arginine, Vitamin C and Vitamin E
◦ *Short Term Use and Clinical Follow-Up for effectiveness recommended
Re-Ignite Your Spark
Taste Testing
239/24/2021
Interventions
The evidence is limited about benefits
from appetite stimulants. While their use
may be appropriate in specific
circumstances, they are not a substitute
for appropriate investigation of modifiable
risk factors and underlying causes of
weight loss.
Interventions
Maintaining Fluid and Electrolyte Balance
◦ Poor fluid intake, abnormal lab values,
medications and resident conditions may
affect a resident’s fluid/electrolyte balance
◦ Offering a variety of fluids during and
between meals, assisting residents with
drinking, keeping beverages available and
within reach, and evaluating medications
(causing dehydration)
◦ Alternate fluids, such as popsicles, gelatin and
ice cream may be offered
249/24/2021
Interventions
Feeding Tubes
TPN
Monitoring
On-going monitoring of care planned interventions is
necessary.
◦ Interviewing the resident and/or resident representative to
determine personal goals and preferences
◦ Direct observation
◦ Interviewing direct care staff to gain information about the
resident, current interventions and what their responsibilities are
for reporting on these interventions (and possible suggestions
for changes)
◦ Reviewing the resident-specific factors and any supplemental
nutrition (relevance, new concerns, new medications, new
diagnosis)
◦ Evaluate to determine if current interventions are implemented
and effective (reviewing weight records, meal monitors, intake
and output logs, nurses notes, lab values and physician or
dietitian assessments)
259/24/2021
Key Elements of NonCompliance
To cite deficient practice at F 692, the surveyor’s investigation will
generally show that the facility failed to do one or more of the
following:
◦ Accurately and consistently assess a resident’s nutritional status on
admission and as needed thereafter
◦ Identify a resident at nutritional risk and address risk factors for
impaired nutritional status, to the extent possible
◦ Identify, implement, monitor and modify interventions (as appropriate),
consistent with the resident’s assessed needs, choices, preferences, goals
and current professional standards of practice, to maintain acceptable
parameters of nutritional status
◦ Notify the physician as appropriate in evaluating and managing causes of
the resident’s nutritional risks and impaired nutritional status
◦ Identify and apply relevant approaches to maintain acceptable
parameters of resident’s nutritional status, including fluids
◦ Provide a therapeutic diet when ordered
◦ Offer sufficient fluid intake to maintain proper hydration and health
Immediate Jeopardy
Repeated, systemic failure to assess and address a resident’s
nutritional status and to implement pertinent interventions based
on such an assessment resulted in continued significant or severe
weight loss and functional decline
Repeated failure to assist a resident who required assistance with
meals and drink resulted in or made likely the development of life-
threatening symptom(s) or the development or continuation of
severely impaired nutritional status
Dietary restrictions or downgraded diet textures, such as
mechanical soft or pureed textures, were provided by the facility
against the resident’s expressed preferences and resulted in
substantial and ongoing decline in food intake resulting in significant
or severe unplanned weight loss with accompanying irreversible
functional decline to the point where the resident was placed on
Hospice
The failure to provide an ordered potassium restricted therapeutic
diet resulted in evidence of cardiac dysrythmias or other changes
in medical condition due to hyperkalemia.
269/24/2021
Actual Harm
Failure to revise an/or implement the care plan addressing the resident’s
impaired ability to feed him/herself resulted in significant, not sever,
unplanned weight change and impaired wound healing (not attributable to
an underlying medical condition)
Failure to identify a decrease in food intake, which resulted in a significant,
unintended weight loss from declining food and fluids, which resulted in
the resident becoming weakened and unable to participate in ADL’s
Failure to assess the relative risks and benefits of restricting or
downgrading diet and food consistency or to accommodate a resident’s
choice to accept the related risk resulted in declining food/fluid intake and
significant weight loss
Failure to accommodate documented resident food dislikes and
preferences resulted in poor food/fluid intake and a decline in function
Failure to provide a gluten-free diet (one free of wheat, barley and rye
products) as ordered for a resident with known celiac disease resulted in
the resident developing GI symptoms, including significant, not severe,
weight loss, chronic diarrhea and occasional vomiting.
No Actual Harm with Potential for
More Than Minimal Harm
Failure to obtain accurate weight(s) and to verify
weight(s) as needed
The facility’s intermittent failure to provide required
assistance with eating resulted in poor intake,
however, the resident met identified weight goals
Failure to provide additional nourishment when
ordered for a resident, however, the resident did not
experience significant or severe weight loss
Failure to provide a prescribed sodium-restricted
therapeutic diet (unless declined by the resident or
the resident’s representative or not followed by the
resident); however, the resident did not experience
medical complications such as heart failure related to
sodium excess
279/24/2021
No Actual Harm with Potential for
Minimal Harm
Failure of the facility to provide
appropriate care and services to maintain
acceptable parameters of nutritional
status, which includes hydration, and
minimize negative outcomes places
residents at risk for more than minimal
harm.
Questions
Thank You!
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