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s a nursing home consultant, I learned to expect the unexpected. You never quite know what is going to happen in the course of a day, but I do admit I was unprepared to witness a physical altercation between the director of nursing (DON) and the dietary manager. It had been a very nerve-wracking week. This particular facility had just been through three intense days of survey, and everyone was feeling the pressure. The unrelenting summer heat of Florida, the long hours, and the even longer list of citations were fraying everyone's nerves. So when the management team was ushered into the tiny conference room to discuss the citations, tempers erupted and the "blame game" began.
       The main point of contention was the food temperature. The dietary manager loudly asserted that the food was the proper temperature when it left the kitchen. "It's those nursing assistants. They never serve the food right away." The DON took offense and retorted that the nursing assistants did serve the meals right away and the problem was indeed in the kitchen. Accusations flew back and forth for several rounds. Soon the argument grew to include the problems with documenting meal intake, the slow follow up on dietary recommendations, and the repetitive snacks. The bottom line was the DON saw many flaws in the dietary department, but the dietary manager saw just as many in the nursing staff. This was clearly an argument all sides were going to lose--especially the nursing home's residents. The stalemate was temporarily ended when it turned physical. And, with that, the meeting was adjourned.

Nursing Versus Nutrition
       The duties of the nursing and nutrition staffs are so intertwined that it is futile to attempt to divide them. These two departments must cooperate on a daily basis in order to prepare, serve, feed, and document three meals and three snacks per day for each resident. That equates to approximately 21,600 meal occasions per month in the typical 120-bed facility. The one and only way to accomplish this monumental task while assuring the best nutritional outcome for each resident and maintaining the sanity of the staff is with cooperation and team work.
       Today's DONs are required to not only be proficient in all aspects of medical care but also be well versed in financial management, legal issues, physical plant management, and human resource management. In most facilities, the DON is responsible for the daily operation of the building. In order to do this job well, the DON must be conversant and knowledgeable about the operation of all the other departments including the dietary department. Just as the DON wears many hats, the dietary manager also has many roles including chef, nutritionist, purchasing agent, sanitary engineer, and dining room host or hostess. With such busy and sometimes stressful jobs, the DON and the dietary manager must plan regular meetings to discuss the interaction and interplay between the two departments. Although facilities should be survey-ready every day of the year, it is only natural that some special preparation will occur in the weeks and months directly preceding the annual inspection. A modified nutrition survey may be just the answer to get the dialogue rolling and problem areas uncovered before the survey team arrives. The nursing administrator can "inspect" the dietary department while the foodservice supervisor examines the nursing areas that impact nutrition. Then they can compare notes and make any desired changes to their systems. If necessary, an outside consultant may be used to moderate or lead this exercise.

What the DON Needs to Know
       The DON's part of this exercise can be divided into three parts: documentation reviews, a dining observation, and a kitchen inspection.
       The first step is to randomly select charts to audit. I recommend that you audit approximately 10 percent of the facility's charts. For example, in a 120-bed facility, the goal should be to audit 12 charts. The purpose of each review is to determine if the nutritional care meets regulatory requirements. However, rather than simply be in the mindset of regulations, it is important to look at the chart as representing a whole person and question whether or not the nutritional documentation reflects logical, sound care. For example, if there is a note that states the resident is lactose intolerant or doesn't like milk, it is logical to question how the resident will meet her daily calcium and vitamin D requirements. Individual situations like this should be addressed in the nutrition section and communicated to the other disciplines via the care plan. Table 1 outlines some of the questions to ask when conducting a nutrition chart audit. It is best to use clinical judgment and common sense when reviewing charts.
       A dining observation can be conducted at any meal or, preferably, at several different meals to observe for patterns and trends. If the facility has more than one dining room, an observation should be conducted in each location. Every published guide to selecting a nursing home for your loved one encourages the family members to observe a meal in the facility. Look at the dining room as if you were an outsider and visualize if this is a place you would feel comfortable leaving your own mother or father. The dining room should be a safe and pleasant place to eat as well as to socialize. Residents with similar functional levels should be seated together. Trays should be delivered to one table at a time so that everyone at that table may begin eating together. Tray set-up is not simply removing the entrée lid but includes opening all the small condiments, such as butter and salad dressing. These tray add-ons not only provide extra calories but also make the food tastier. Beverages should be opened and placed within reach of the resident. Those residents that require total assistance should be allowed sufficient time to complete their meals. Spoon-feeding takes time and should be done at a speed comfortable for the resident. Any resident who does not enjoy or complete her meal should be offered an alternate food selection. Food temperatures should be taken on the last tray delivered. It is helpful to send a test tray as the last tray so that you have a complete meal to inspect. Determine the percentage of residents who eat meals in their room. A very high percentage may indicate that residents do not feel comfortable in the dining room. Overall, the dining room should be organized and the meal should flow smoothly and efficiently.
       A kitchen inspection is the final component of the DON's review of the nutrition department. Although there are many technical aspects of a full kitchen inspection, common sense can be used to guide any casual observer. The DON may not know the precise temperatures required for the dish machine's final rinse cycle, but another pair of eyes can be very useful for identifying many potential citations. Simply put, the kitchen should be clean and organized. Table 2 lists some of the items to look for during the kitchen tour.
       After completing the chart reviews, observing a few meals, and touring the kitchen, the DON will likely have a list of items that need to be discussed with the dietary manager. This discussion should be constructive and not critical. The goal is to correct any and all identified problems before the state inspection takes place. It is very difficult to devise new systems and figure out how to correct problems while in the midst of a survey.

What the Foodservice Director Needs to Know
       In order to complete this survey preparation exercise, the foodservice manager should also examine the areas where nursing impacts the dietary department. It is difficult to definitively classify certain citations as belonging to nursing or nutrition because of the overlap in responsibilities. For example, let's suppose that a nurse or a nursing assistant incorrectly records a resident's January weight as 120 pounds rather than 110 pounds. In February, the weight is correctly recorded as 105 pounds. It appears that this resident lost 15 pounds in one month when the actual weight loss is closer to 5 pounds. An error, such as this, typically would fall under the nutrition regulation for maintaining acceptable parameters of weight. Members of the nutrition department may feel that since they don't physically weigh the residents, this is not their problem. This is just one example to illustrate why a facility culture of cooperation and team spirit is imperative. Unless the problems are ferreted out in advance and corrected, no one wins. But that requires knowing what to look for.
       Involuntary weight loss is perhaps one of the most rampant problems facing nursing homes today. With that in mind, the weight book may be the starting point of the exercise. A quick review of the weight logs will indicate if any weights are missing or if the recorded weights simply don't make sense. The dietary manager or dietitian should observe the nurses weighing several different residents and make certain that the procedures are consistent and correct. The scales should be calibrated to be sure they are accurate. Procedures for weighing bed-bound residents, morbidly obese residents, and those with casts, splints, and other devices should be reviewed. In accordance with Murphy's Law, it is always the atypical resident that will be weighed during the actual survey.
       The dietary part of this internal survey exercise should also include a dining observation. The dietary manager should observe the distribution of meals, the tray set-up procedures, and how residents with poor meal intake are handled. Encouragement, verbal cues, and hand-over-hand and modeling techniques should be used as necessary. Meal substitutes and second helpings of favorite foods should be offered as needed. It is important to take note of the amounts a random sampling of residents consumed and then compare the observations to the actual amounts recorded on the meal intake log. Accurate recording of meal intake is a trouble spot for many facilities that can only be remedied once it is identified and proper training takes place.
       The dietary manager should tour the resident rooms. One part of assuring proper hydration is to make sure that all residents (except those on a fluid restriction) have beverage pitchers available that are accessible, clean, in good repair, and refilled often. Identify all residents on a fluid restriction and check to see if the restriction is communicated to the entire team. Observe the nurse administering medications and see how much fluid is offered. The same observations and double checking should be done for any residents on thickened liquids as well. Take note if unopened canned supplements are stacking up anywhere and, if so, find out the reason why. Many families bring in cookies and other snacks from home. Check nightstands to see if open food packages, crumbs, or bugs are a problem.
       The snack program is another area of overlap between the two departments. The dietary manager should observe how snacks and medical nutrition supplements are distributed. Are cans and straws opened? Is assistance given? Most nursing homes have a snack room. Inspect this room for orderliness and cleanliness. The same standards apply in small satellite kitchens, nourishment rooms, and the employee break room as in the main kitchen.

Planning the Plan
       Once both department heads have completed their reviews, they should come together with their findings. The purpose of this meeting is not to accuse or point fingers but to work out a plan that will correct the problems and ease everyone's tension come survey day. The attitude must be one of gratitude for identifying these problems while there is still adequate time to fix them. It is much more constructive to iron out system flaws on your own terms rather than as part of your survey's mandated plan of correction. The recipe for a successful nutrition survey is one part communication, one part interdepartmental cooperation, and one part knowing what to look for. After that, the only conflict once the surveyors depart will be what toppings to order for the celebratory pizzas!