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Nutrition and HydrationF 692

Re-Ignite Your Spark

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Re-Ignite Your Spark

F 692 Current Regulatory TrendsData 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

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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.

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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.

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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.

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Certified Dietary ManagerF 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

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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.

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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

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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

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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)

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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.

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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.

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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

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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

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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 ProteinUsage: 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)

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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 SparkTaste Testing

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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

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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)

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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.

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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

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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.

QuestionsThank You!