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In Perspective

May 1, 2004
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Survey Survival Correcting Those Nutritional Deficiencies by Reta A. Underwood, ADC

SURVEY survival

Correcting those nutritional deficiencies In reviewing government and industry reports benchmarking LTC quality of care, one sees that percentages rule-percentages of residents impacted by a particular Quality Indicator (QI), and percentages by which performance on that QI has progressed or regressed. It's easy to forget that behind these percentages are "real numbers" involving real people. The truth for our nursing facilities is that while a 1% shift might not be perceived as an industry trend, it may positively or negatively affect an additional 15,000 residents in a very real way.

When it comes to nutritional services, the reality is that neither the percentages nor the real numbers of deficiencies cited during the past five years have improved-they have, in fact, gotten worse. In particular, the three key nutrition F-Tags under Quality of Care (F-325-327) that can result in citations for substandard quality of care and immediate jeopardy were cited more frequently on average during the period from 1999 to 2003 than in 1998. For F-325 (acceptable parameters of nutrition), this means that 1,400 nursing facilities caring for as many as 150,000 residents were each cited annually (on average) for this key deficiency during that five-year period.

Without doubt, maintaining good nutritional parameters is a necessity, not a luxury, for every resident living in our nursing facilities. Consider these staggering numbers:
  • In 2002, an estimated 700,000+ residents required some sort of help in eating, which represented tens of millions of manpower hours.
  • A study published in the Journal of the American Dietetic Association found that nursing assistants inaccurately estimated residents' food intake more than half the time, which means that inaccuracies were recorded for hundreds of millions of meals per year.
  • Average annual turnover for dietary services personnel approaches 50%, constituting tens of thousands of people, according to the "AAHSA Nursing Home Salary and Benefits Report 2002-2003," published by Hospital and Healthcare Compensation Service.
Thanks to outstanding research and data provided by Cowles Research Group in Montgomery Village, Maryland, as well as expert feedback from leading dietary professionals, here are the realities, the challenges, and some simple survey survival techniques for frequently cited nutritional and dietary deficiencies. These apply to key deficiencies beyond the three mentioned above.

Reality #1: F-371 Sanitary Conditions (not one of the "big three") continues to be the most cited deficiency. About 5,000 facilities fail to meet this minimum standard each year. Much of the reason for this is because "so much falls under sanitation. Sanitation is more than cleanliness. Food storage, preparation, distribution, and the serving of food under sanitary conditions are all included under F-371 Sanitary Conditions," according to Debra D. Dawson, CDM, CFPP, chairman of the board of the Dietary Managers Association and nutrition services director of Bishop Drumm Retirement Center in Johnston, Iowa. How serious is this as a general issue throughout the United States? The American Dietetic Association's Food and Water Safety Survey from September 2003 estimates that every year there are 76 million cases of foodborne illness, 325,000 cases of food-related hospitalizations, and 5,000 corresponding deaths.

Challenge: Compliance with survey requirements depends on all staff, not just the dietary department, doing their jobs regarding sanitation. Consider assigning your own sub-tags in a mock survey, for example, thus allowing you to focus on any out-of-compliance areas and reinforce compliance in crucial areas, such as safe handling of food, proper storage, and implementation of proper sanitation procedures.

Survey Survival Techniques: Providing in-depth education on proper food storage, preparation, distribution, and serving to all staff is a must.

Reality #2: F-364 Food prepared by methods that conserve nutritive value, flavor, and appearance; food that is palatable, attractive, and at the proper temperature. Or, simply stated, your food quality. In 2003 alone, more than 1,200 facilities were found to be noncompliant. When was the last time you ate the pureed food served at your facility?

Challenge: Pureed foods, modified textures, therapeutic diets, and thickened liquids all pose unique challenges for the dietary department. Our residents, their families, and surveyors have set a higher standard and expectation than ever for the food that we serve. If we don't meet the challenge, our residents will continue to experience weight loss and dissatisfaction, and facilities will continue to be found nutritionally deficient. In interviews with Dawson; Carolyn Breeding, RD, LD, FADA, president of Dietary Consultants, Inc.; and Marianne Smith Edge, MS, RD, LD, FADA, president of the American Dietetic Association, all three agreed that the quality of food is of paramount importance and must improve industry-wide to see a rise in resident satisfaction and overall improvement of their nutritional condition.