Should Nutrition and Hydration be a Priority for Administration?

Annette M. Kobriger, RD, CD, MPH, MPA

Nutrition, hydration, and pressure ulcers are hot topics in long-term care. Not only is the Health Care Financing Administration (HCFA) looking at these issues for survey concerns, but civil lawsuits (especially in Florida) are bringing awards to plaintiffs in the million-dollar range. In Connecticut, an administrator and a director of nurses were taken in handcuffs from their facility on a criminal case involving pressure ulcers.

Surveyors and lawyers are now more interested in process than resident outcomes. The outcomes are considered unacceptable in many cases, so now the investigation focuses on what went wrong. Think about the policies and procedures at your facility. Are they operational, or are they on paper only? If a lawyer or a surveyor was looking at poor resident outcomes regarding nutrition, pressure ulcers, and hydration, the following are evaluated. Think about your facility and the answer you would give to each question.

1. ;Is food intake accurately monitored? Does the nutrition professional have accurate information for making clinical decisions?

2. ;Does the care plan match what is happening in the dining room? Are fluids encouraged? Is food served in bowls for specific residents? Do residents receive the assistance designated on the care plan--always? Are residents positioned properly? Are they promptly fed per the care plan? Is the food on the tray correct for the diet and the texture required?

3. ;Are there holes in the food intake documentation? Lawyers interpret this as, "The resident was not fed."

4. ;Are substitutes offered? Are food preferences, including small portions, honored?

5. ;Is the resident assisted with seasoning food, opening cartons, and cutting up meat?

6. ;Are food supplements delivered and recorded as given, yet full cartons found with the same date and resident name?

7. ;Are snacks passed at night? Are they recorded as given, but remaining in the serving areas?

8. ;Are the nutrition and hydration assessments refigured when a resident has an infection or a broken hip?

Do the systems in your facility work, or are they on paper only? The Corporate Compliance program voluntarily advocated by Medicare asks, in the early steps, "Are your policies and procedures operational?" If these policies and procedures are on paper and not operational, this is a perfect set-up for a deficiency or lawsuit. Be proactive. HCFA has made its expectations clear in the regulations, in the interpretive guidelines, in the Quality Indicators, and in the Investigative Protocols. What are we waiting for in long-term care? Why wait for the citation? The administrator is considered the coordinator of the staff and is instrumental in staff members working together for the benefit of the residents. ***