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Nutrition Is More Than the MDS, Section K

February 1, 2002
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What a good assessment really involves by Brenda E. Richardson, MA, RD, CD
Nutrition Is More Than the MDS, Section K If you think this information is all you need to monitor and meet residents' nutritional needs, think again by Brenda Richardson, MA, RD, CD After practicing as a registered dietitian for 20 years and understanding the importance of nutrition in long-term care, I am amazed to still see nursing facilities not appropriately identifying residents who are nutritionally at risk. In the past several years, I have been directly involved with helping many facilities correct survey deficiencies relating to nutrition and hydration. These facilities, prior to their surveys, thought that their nutritional programs were effective. Needless to say, facility staff were surprised and alarmed to learn that because residents were not being identified as nutritionally at risk, actual harm and even death were occurring. Resident nutrition and hydration are-and should be-closely scrutinized by state and federal surveyors. Malnutrition in elderly populations is associated with poor clinical outcomes and is an indicator for increased mortality. Residents with severe malnutrition are at higher risk for a variety of complications, and conversely, a number of chronic medical conditions are associated with increased risk of malnutrition.1

So it is disturbing to find that the number one reported survey deficiency across the nation in the year 2000 for Medicare- and Medicaid-certified nursing facilities (28.8%) was F371: Food Sanitation and Safety. And Nutrition F325-the tag that ensures that residents maintain acceptable parameters of nutritional status, given their clinical condition and interventions employed-was a cited deficiency in almost one in ten facilities in 2000. Revisions of the State Operations Manual for F325 and F371 are forthcoming, and will no doubt incorporate nutritional "best practice" guidelines to aid facilities in their provision of services.

Facilities with successful nutritional programs all understand and support two primary principles, but some facilities are misguided by some common misconceptions. Recognizing these misconceptions and offering practical solutions for them will promote effective nutritional care provided daily by all facility staff.

Principle #1: Clinical Nutrition Is More Than Section K of the MDS

Although it is important for administrators and directors of nursing services to recognize Section K as the MDS section relating to oral/nutritional status, it is also vital to understand that nutrition is integrated throughout the overall RAI process. In fact, there are more than 60 MDS items that are guidelines or triggers that the clinical team should consider when completing the Resident Assessment Protocols (RAPS) for nutrition, dehydration/fluid maintenance or placement of feeding tubes. However...

Common misconception #1: "A comprehensive nutrition assessment includes information from Section K of the MDS only."

Solution: A comprehensive nutrition assessment should incorporate a review of all MDS triggers or guidelines related to a resident's nutritional status. Such an assessment considers the resident's "total picture," as presented by the MDS and, as such, facilitates creation of an accurate and complete resident care plan.

While there are many assessment forms and tools used by nutrition professionals across the nation, registered dietitians have desperately needed a comprehensive tool that supports the MDS format, incorporates best practices, permits accurate determination of nutritional risk and promotes effective time management for medical record documentation. As it happens, that tool is now available from Consultants for Long Term Care, Inc. (See Figure and "Guidelines Available").

Common misconception #2: "I don't have time to review all of the guidelines and RAPS related to nutrition."

Solution: Remember that a comprehensive nutritional assessment is not comprehensive if there are nutritional factors noted on the MDS but not considered in the overall assessment. Not considering these factors can result in untimely and inconsistent documentation, a need for recalculations or reassessment, a lower PPS reimbursement, and a lack of early identification and intervention, resulting in later, more costly nutritional intervention. Much of this involves additional-and wasted-time and increased costs.

Principle #2: Facility Systems and Processes Must Be Implemented by a Team to Achieve Successful Monitoring, Identification and Management of Nutritional Problems

Effective nutritional care depends on support from many programs, disciplines and departments. However...

Common misconception #1: The registered dietitian and dietary department are solely responsible for the nutritional care of the resident.
Solution: Recognize the need for interdisciplinary teamwork, taking into account the facility's:

'Hydration program
'Supplement program
'Weight program
'Dining program
'Skin care program
'Behavior management program
'Quality improvement program

Common misconception #2: The facility can use weight loss as the indicator for identifying and monitoring residents' nutritional risk.

Solution: While weight loss is one indicator that can be used for this purpose, there are many others. Key indicators for residents being nutritionally at risk include (but are not limited to):

'Unplanned weight loss or gain
'Presence of pressure ulcers/skin dis-orders
'Need for enteral feedings
'Presence of dehydration/inadequate fluid intake
'Abnormal lab values