Nutrition Ink

1
Welcome
2
What we will cover in this presentation

• What makes a successful consultant
• The Dos and Donts in charting
• Verbs to describe professional intervention
• Comparison in charting
• Proper identification of individuals in the
  healthcare setting
• Menu, Production sheets and recipes
• Diets available in the facilities
• Diet Orders
• Non Specific Diet Orders
• Policy and Procedure manual
• Diet Manual
• F Tag 325 Now you be the Surveyor by Linda
  Handy, RD

3
What Makes a Successful Consultant?

• Expertise in the field
• Ability to solve problems and leave the personnel
  with a Win-Win feeling
• Avoid Oral Contracts. People forget and it
  doesnt hold up in court
• Ability to negotiate contracts and knowledge base
  to know the number of hours needed to do the job
  and the FORTITUDE to walk away if needed.
• Ability to Work with Others and have them WANT to
  work with you. That is an attitude that you
  possess and others want to follow your advice
• Flexibility is an asset work with clients and
  know their needs
• Dont take on a heavier workload than you can
  handle refer the work on
• Be disciplined in time management
• Know the chain of command and that you are giving
  advice and are not the final word. You are there
  to keep them out of trouble but you must not beat
  them over the head.
• Knowing when to push is important and knowing
  when to walk away from a client that doesnt heed
  your advice that is critical to patient care.
• Knowing ADAs Code of Ethics
• Having a knowledge base of Systems that need to
  be in place for the facility to be successful.
  Your own tools can be a great selling point

4
Objectives for the Consultant Dietitian

• Assess and facilitate delivery of effective
  nutritional care to individuals by working
  through facility staff
• Plan and implement nutritional care for all
  individuals
• Evaluate the foodservice system on a regular
  basis, making recommendations that will provide
  high standards for quality, nutritionally
  adequate food that meets individual needs and
  preferences
• Assist in developing budget proposals and cost
  control procedures consistent with facility
  policies
• Assist in determining and developing dietary
  personnel policies.
• Assist in the planning, organizing, conducting,
  and evaluating of staff development programs

• Determine equipment needs for new or existing
  foodservice facilities and assist in planning
  layout design.
• Recommend standards and monitoring competency,
  procedure, and practices for safety and
  sanitation
• Develop, maintain, and use pertinent record
  systems
• Follow current research, literature, trends
  relating to nutrition care and effective dietary
  management.
• Promote effective inter- and intradepartmental
  communications and public relations.
• Assist the facility in maximizing servies and
  presenting nutrition-related services to the
  community

5
Successful ConsultingStep by step

• Before going to facility have all materials
  ready. Also remember never discuss another
  facility unless you have a favorable comment to
  make
• Entrance with administrator Allow administrator
  to discuss any problems or areas he/she wishes
  you to concentrate on
• Meet with DSS. Chit chat briefly on a personal
  level. Let him/her know what your goals are for
  the visit. Allow them to advise you on any
  current problems that need your assistance.
• Review Kardex.
• Do new admits first second problem individuals
• Check with admissions office to be sure that you
  have all the new individuals. DSSs sometimes
  forget to write in Communication Book.
• Check for annual assessments
• Check kardex cards for diagnosis, allergies and
  food preferences. NO individual likes
  everything. If blank, emphasize the none
  stated must be written
• Check current diet orders to make sure they
  coincide with menu and diet manual.

• Discuss inservice with DSS. Check inservice
  manual to make sure that inservices assigned to
  DSS have been completed.
• Make observations as you walk through kitchen
• Check menu for the day
• General sanitation
• Charting
• Briefly check DSS comments and data on screening
• Make recommendations that are realistic and that
  staff can follow through with
• Prioritize the individual P1 at nutritional
  risk monthly RD charting P2 DSS to follow
  closely and report to RD P3 DSS to chart on
  quarterly RD annually

6
Successful Consulting Continued

• Get last months consultant report to check on
  problem individuals to see if DSS and nursing
  have followed through, this should be done on the
  second visit to allow time for staff.
• If note left for M.D. check to see that a
  response has been documented. Can also tag
  kardex if note left to M.D. for easier follow-up
• Observe trayline Check trays of new
  individuals check at least two therapeutic
  diets. Check for low sodium food if facility has
  2-3 gm sodium restriction or Renal. Is the menu
  production sheets out and being used during
  serving?
• Monthly QI. There are 3 specific QIs that are
  done in a quarter. This does not mean spot
  checking isnt to be done especially for
  sanitation.
• Check disaster foods on hand and disposable
  dishes. Disaster foods do not need to be kept
  separate from the regular stock.

• Food Temperatures
• Check foods on steam table
• Check that food wasnt cooked to soon
• Encourage batch cooking
• Request test tray check food temps..make it the
  last tray served. Also evaluate for quality
• Check temp of food store rooms
• Are foods properly covered for transport..if it
  goes down hallway everything needs to be covered.
• Is there any temperature retention system in
  place? E.g., hot cart, heated plates, insulated
  lid and plate holder, enclosed cart, unitized
  heated base, pellet system
• HACCP procedures are they in place and being
  followed?
• Storage Areas
• Are personal belongings in the storeroom?
• One weeks of staple goods and 2 days perishable
  foods on hand use menu to check
• Proper storage rotation of food rotated on 6
  month basis (canned items) other requirements
  for spices etc. refer to policy manual
• Menu posted
• Are two weeks of the regular menu posted on a
  consumer bulletin board? Are they dated?
• Does the DSS make changes on the posted menus for
  the individuals

7
The Dos Do NOTs in Charting

• Do write legibly
• Do identify the resident on each page of
  documentation
• Do use black ink
• Do not alter the records or allow for suspicion
  of tampering. (i.e., explain changes in ink
  (error and then initial), do not leave blank
  lines.)
• Do sign the entry and indicate your professional
  title
• Do correct errors properly
• Do use only authorized abbreviations.
• Do spell correctly.
• Do document in a timely manner
• Do delineate resident care rendered and clinical
  information supplied by another provider and
  indicate the source of the information
• Do NOT blame or criticize another provider in the
  resident record
• Do NOT express personal feelings about a resident
  in the record
• Do document findings objectively and be specific
• Do NOT record hearsay as fact
• Do be careful when countersigning another
  providers documentation (e.g, dietitian student,
  new orientee)

8
The Dos Do NOTs in ChartingContinued

• Do document non-compliance with treatment orders
• Do document results of lab work
• Do not alter existing documentation
• Do NOT make remarks concerning the residents
  personality traits or idiosyncracies unless they
  are pertinent to the residents treatment.
• Do document in a concise and accurate manner.
• Do observe the rules of strict confidentiality in
  handling documentation
• Do document threats or discussion by the
  resident/family
• Do NOT document in the chart Will request DON to
  check for accuracy in recording of
  supplementation on MAR.
• Do NOT document in the chart dietary consult was
  ordered of which I wasnt made aware
• Do NOT document in the chart Nx was ordered TID
  on (1 month ago) and only started receiving them
  today
• Do NOT document in the chart ANYTHING that
  buries the facility, i.,e., alerts surveyors to
  potential problems. This is NOT our job. Bring
  things to the attention of the administrator,
  DON, Dietary supervisor. Document this in a
  separate note. Putting on Consultant Dietitian
  Report will bury the facility also. Do cover
  yourself.

9
Verbs to describe professional interventions

• Advised
• Assessed
• Assisted
• Clarified
• Confronted
• Counseled
• Discussed
• Directed
• Maintained
• Developed
• Encouraged
• Focused
• Identified
• Interpreted
• Reassured

• Recommended
• Referred
• Reflected
• Coordinated
• Structured
• Supported
• Urged
• Demonstrated
• Taught
• Reviewed
• Instructed
• Modified
• Implemented
• USE THEM WITH PRIDE!!!!

10
Charting Comparison

• Original Note

• Re-worded

• f/u new wt 108 ? since admit. BMI 18. When
  pt was first admitted she was on Marinol to ?
  appetite and on Remeron. Chart review reveals
  d/c of Marinol by Dietary Manager on 11/13/08.
  No order for Remeron d/c noted however cant be
  found on med recap sheet for December. 3 day
  food log reveals 50 intake q meal usually and
  100 intake of healthshakes. When pt first
  admit, she was eating 100 and requesting food
  b/t meals. Now pt isnt. Spoke with DON
  regarding d/c of Marinol by Dietary Manager and
  no Remeron. DON states she will take care of
  situation and re-write order.
• P 1) Fortified regular diet
• 2) Adding back appetite stimulant. Monitoring

• f/u new wt 108 ? since admit. BMI 18. 3 day
  food log reveals 50 intake q meal usually and
  100 intake of healthshakes. Marinol d/cd
  11/13/08. Resident noted to no longer be
  requesting food between meals
• P 1) Fortified regular diet
• 2) Add back Marinol for appetite stimulation
• List on a separate paper, what is
  inappropriate/wrong with the original note vs the
  re-worded note. And why.

11
Proper identification

• Resident Nursing home.
• Consumer ICF DD home
• Patient Acute Hospital or at home client

12
Menus and Production Sheets

• Diet Manual
• Diets available in the facility
• Textures available
• Appropriate Diet Orders
• Non-specific Diet orders
• How to read the production sheet
• How to read a recipe

13
Diet Manual

• Nutrition Ink has available our medical nutrition
  diet therapy manual for the SNF and RFEs. Some
  facilities have chosen to use a corporate diet
  manual or a diet manual supplied by their vendor
  e.g., Sysco.
• The California State diet manual for DDS is used
  in the DD homes with some update/changes done by
  Nutrition Ink.
• The diet manual has specifics available on each
  diet. The menus are written based on this manual
  as is the standard. There are additional diets
  available in the diet manual that may be used on
  an individual basis.
• A finger food menu written to correspond to each
  facilities (SNF) menu, if requested, is also
  available. General guidelines are in the diet
  manual.

14
Diets Available in the facility

• Regular
• Fortified (nutrient dense)
• 2-3 gm Sodium
• House Renal (60-80 gm Pro, 2-3 gm Sodium, 2-3 gm
  K, 1-2 PO4)
• House Renal LCS
• 1200-2000 cal diabetic
• Consistent Carbohydrate Diet (CCD) aka
  Liberalized diabetic
• Lowfat/Low Chol
• Liberal Bland
• High Protein
• High Fiber
• Low Residue

• Small Portions
• Large Portions
• Pre-Dialysis
• Finger Food
• No Added Salt (NAS) lt 5 gm Na
• Detailed explanation of each diet is available in
  the diet manual and a summary is available in the
  policy and procedure manual.

15
Diet Orders

• Diet orders have two categories to them
  therapeutic orders and texture modifications
• Therapeutic orders are diet modifications that
  are instituted to treat a disease state.
• Texture modifications are orders that modify the
  consistency of the food to ease chewing and
  swallowing problems, or fatigue that may occur
  during meals, or dexterity problems.
• Diets should be liberalized in LTC and DDs.
  Refer to position paper of ADA on liberalized
  diets in LTC.
• In the DDs simplified diets are easiest for
  staff to follow. Direct Care Staff are not
  highly educated.

16
Non specific diet orders

• Non-specific

• Interpreted as

• Low salt, low sodium, mild sodium
• Diabetic
• Mechanical soft, dental soft, regular soft
• Bland

• No Added Salt
• Consistent Carbohydrate Diet
• Regular with ground texture
• Liberal Bland

17
Diet Order exampleCorrect vs incorrect

• Regular, CCD,1800 cal ADA, ground with chopped
  meats
• 2 gm sodium, NAS, regular, puree
• House Renal LCS, 2 gm sodium, dental soft

• CCD ground
• NAS, puree
• House Renal LCS, ground

18
How to Read the Production Sheet
19
NutriNet Food Management System Daily Menu
Spreadsheet for SNF Master cd08 Day 1 Nurition
Ink/Week One
1
3
Ghost Recipe Numbers 5
4
2
7
6
8

• This is what day number of the cycle e.g., menu
  starts on Monday, Week One day 1 of 42 day
  cycle cd08
• is the cycle menu name
• Regular diet with portion sizes
• Recipe numbers used for the meal. These are the
  ONLY ones that occur in the recipe book
• Record internal temperature of items indicated
  HINT minimum temperature is listed.
• Ghost Recipes, ANY recipe number occurring
  other than what is in the REGULAR column. These
  are for Nutrition Inks
• computer system ONLY. They do NOT print in the
  recipe book. The diet instructions fortified,
  pureed, ground,
• chopped, renal, renal lcs, 2-3 gm sodium
  diabetic/wt control, CCD, Liberal Bland are all
  on the regular recipe.
• Puree column what to puree and portion size to
  serve refer to REGULAR recipe for instructions.
• Ground same as mechanical soft includes
  portion size to serve once regular item is
  ground.
• See Rec this means that there is specific
  information for diet modification on the REGULAR
  recipe.

20
Third Page of Production Sheet

• Liberal Bland Omit caffeinated, decaffeinated
  beverages and chocolate
• NAS Serve regular diet with No Salt Packet on
  tray
• Hi Protein Serve 8 oz milk and 1 extra oz
  protein at each meal
• Low Residue White breads only (when on menu).
  No raw fruits or vegetables except banana. Limit
  milk to 16 oz per day
• Hi Fiber Serve whole wheat bread, 8 oz water
  every meal, use hi fiber cold cereal, 1 raw
  fruit/vegetable per day
• Small portions 2 oz protein, ¼ cup starch, 4 oz
  milk
• Large Portions 1 ½ servings of meat, starch,
  vegetable, 8 oz milk
• Puree/Ground/Chop/Dysphagia if mashed potatoes
  occur on the menu for texture modification add 1
  oz (2 tbsp) gravy
• Pre-Dialysis follow renal diet 1 oz protein
  per meal (3 oz total per day) 1 bread/starch at
  lunch 1 bread/starch at dinner
• Lowfat/Lowchol follow CCD diet 8 oz NF milk
  each meal and HS regular condiments no bacon
  no sausage use egg substitute when eggs are on
  menu
• When menu states see rec (see recipe) refer to
  recipe for additional texture modification(s)
  and/or diet modification(s)

21
How to Read the Recipe
22
NutriNet Food Management System Recipe Book
Nutrition Ink 1935 HOW TO READ A
RECIPE.. Srv Utl Tongs/Scoop Size/Ladle/Scale
Portion Size 3 OZ Yield 1 1 Portions 2
Extended HACCP Procedure INGREDIENT BY WEIGHT
1 OZ 2 OZ PHF once cooked INGREDIENT BY
VOLUME 2 TBS 4 TBS Cook to internal temp of
155 Deg F SUB RECIPE NUMBER R 2387 1 1 EA
PORTIONS 2 1 EA PORTIONS HACCP
INSTRUCTION Maintain holding temp 140Deg F or
above HACCP INSTRUCTION Maintain cold
holding temp 38-41 Deg F HACCP
INSTRUCTION Cool from 140to 70 deg F within 2
hours HACCP INSTRUCTION Cool from 70 to 41
deg F within 4 hours Methods Instructions on how
to produce the recipe. CCP THIS NOTATES CRITICAL
CONTROL POINT WHICH MEANS YOU HAVE TO BE AWARE OF
A TEMPERATURE OR METHOD OF PREP. DIETS FOLLOW
INSTRUCTIONS BY DIET. YOU WILL BE INSTRUCTED ON
HOW TO MODIFY THE RECIPE IF IT IS POSSIBLE OR
INSTRUCTED THAT ISN'T APPROPRIATE TO BE SERVED.
THEN YOU WILL NEED TO CHECK THE MENU ON WHAT IS
TO BE SERVED. NOTE The menu takes precedence
over the recipe in terms of which instructions to
follow for a particular diet. 1. SRV UTL
(Serving utensils) Scoop size ladle tongs etc
if appropriate are indicated 2. PORTION SIZE
AMOUNT TO BE SERVED. Additional information on
portion is occasionally indicated in the recipe
instructions. 3. YIELD THE NUMBER OF SERVINGS
THE RECIPE IS BASED ON BEFORE IT IS EXTENDED OR
THE DEFAULT RECIPE SERVINGS 4. Ingredients 5.
Ingredient list based on default recipe
servings. 6. Scaled recipe number of servings
(Extended portion). And ingredient list to
make. 7. HACCP instructions for specified
item(s) 8. SUB RECIPE NUMBER 8a. - "R"
followed by a number is for a sub recipe which
will follow the main recipe when printed. 8b. -
In the second and third columns the servings will
resemble the following 2 2 each - Meaning the
number of servings to prepare of the sub recipe
based on the portion size of the sub recipe 9.
Diet instructions are given for therapeutic and
texture modifications on each of the recipes.
7
1
5 6
2
3
4
8
8b
9
23
Policy and Procedure Manual
24
Policy and Procedure Manual

• Nutrition Ink has a both SNF and DD H N policy
  and procedure manuals that are available to each
  facility.
• Recently updated (2008) to F-Tag 325 371
  standards and also the 2005 Food Code.
• It is suggested that the manual(s) are reviewed
  and that the consultant is familiar with.

25
Now, You be the Surveyor

• LINDA HANDY, MS,RD
• RETIRED SPECIALTY SURVEYOR,
• CA DEPT PUBLIC HEALTH
• WWW.HANDYDIETARYCONSULTING.COM

26
DEFICIENCY CATEGORIZATION Key elements for
severity determination Tag F325 pg.28 Adv Copy

• Once the team has
• Completed its investigation
• Analyzed the data
• Reviewed the regulatory requirements
• Determined that noncompliance exists
• The team must determine the (scope) and severity
  of each deficiency, based on the resultant effect
  or potential for harm to the resident.
•  

27
BEAT THE GRIDHOW TO DETERMINE WHERE A
DEFICIENCY WILL FALL
28
SCOPE HOW MANY?

• EXAMPLE
• D level Isolated (1 or 2 residents)
• E level Pattern (Several residents)
• F level Widespread (Through out facility)

29
Key elements for severity determination for Tag
F 325

• 1. Presence of harm/negative outcome(s) or
  potential for negative outcomes due to a failure
  of care and services. Actual or potential
  harm/negative outcomes for F325 may include, but
  are not limited to
• Significant unplanned weight change
•  
• Inadequate food/fluid intake
•  
• Impairment of anticipated wound healing
•  
• Failure to provide a therapeutic diet
•  
• Functional decline and
•  
• Fluid/electrolyte imbalance.
•  

30
Key elements for severity determination for Tag
F325

• 2. Degree of harm (actual or potential) related
  to the noncompliance. Identify how the facility
  practices caused, resulted in, allowed, or
  contributed to the actual or potential for harm
•  
• If harm has occurred, determine if the harm is
  at the level of serious injury, impairment,
  death, compromise, or discomfort and
•  
• If harm has not yet occurred, determine how
  likely the potential is for serious injury,
  impairment, death, compromise or discomfort to
  occur to the resident
•  

31
Key elements for severity determination for Tag
F325

• 3. The immediacy of correction required.
  Determine whether the noncompliance requires
  immediate correction in order to prevent serious
  injury, harm, impairment, or death to one or more
  residents.
•  
• The survey team must evaluate the harm or
  potential for harm based upon the following
  levels of severity for Tag F325.
• First, the team must rule out whether Severity
  Level 4, Immediate Jeopardy to a residents
  health or safety exists by evaluating the
  deficient practice in relation to immediacy,
  culpability, and severity

32
Severity Level 4 Considerations Immediate
Jeopardy to Resident Health or Safety

• Immediate Jeopardy is a situation in which the
  facilitys noncompliance
• With one or more requirements of participation
  has caused/resulted in, or is likely to cause
  serious injury, harm, impairment, or death to a
  resident and
• Requires immediate correction, as the facility
  either created the situation or allowed the
  situation to continue by failing to implement
  preventative or corrective measures.

33
Access Appendix Q Surveyor Guidance on
Immediate Jeopardy

• www.cms.hhs.gov
• Go to-gt Regulations/Guidance-gtClick on
  Manuals-gtGo to right hand and scroll to Internet
  Only-gtGo to Publications 100-07 State
  Operations Manual (SOM)-gtScroll down to
  APPENDICES
• Appendix P Survey Process
• Appendix PP All the tags and Interpretive
  Guidance
• Appendix Q Guidance on Immediate Jeopardy

34
IJ TRIGGER IN APPENDIX QFailure to provide
adequate nutrition hydration to support
maintain health.

• 1. Food supply inadequate to meet the nutritional
  needs of the individual
• 2. Failure to provide adequate nutrition and
  hydration resulting in malnutrition e.g., severe
  weight loss, abnormal laboratory values
• 3. Withholding nutrition and hydration without
  advance directive

35
SEVERITY LEVEL 3 ACTUAL HARM NOT IJ

• Severity Level 3 Considerations Actual Harm that
  is not Immediate Jeopardy
• Level 3 indicates noncompliance that results in
  actual harm that is not immediate jeopardy. The
  negative outcome can include, but may not be
  limited to clinical compromise, decline, or the
  residents inability to maintain and/or reach
  his/her highest practicable level of well-being.

36
SEVERITY LEVEL 2 NO ACTUAL HARM, POTENTIAL FOR
MORE THAN MINIMAL

• the resident was at risk for, or has experienced
  the presence of one or more outcome(s) (e.g.,
  unplanned weight change, inadequate food/fluid
  intake, impairment of anticipated wound healing,
  functional decline, and/or fluid/electrolyte
  imbalance), due to the facilitys failure to help
  the resident maintain acceptable parameters of
  nutritional status.

37
SEVERITY 1 NO ACTUAL HARM, POTENTIAL FOR MINIMUM
HARM

• The failure of the facility to provide
  appropriate care and services to maintain
  acceptable parameters of nutritional status and
  minimize negative outcomes places residents at
  risk for more than minimal harm.
• Therefore, Severity Level 1 does not apply

38
SURVEYOR MO LEARNING TO DO WHAT THEY DO

• OBSERVE
• -Is staff providing assistance , encouragement,
  positioning, supervision? Adaptive aides?
• -Staff acting on altered status, dental oral?
• Is resident able to access or ask for fluids?
• Are fortification or ordered supplementations
  being given monitored? Accepted? If not, why?
• -Food served Per diet, menu plan, preferences?
• -Tube fdg Hang time, handling, meds, as ordered?

39
SURVEYOR MOLEARNING TO DO WHAT THEY DO

• RESIDENT INTERVIEW
• -Care Per choice, meets needs, planned wt loss
• -Complaints or requests honored
• -Education on choices, Counseling if refusals
• STAFF INTERVIEW (CNA)
• -Monitors intakes, possible deficits?
• -When decline in intake, reported to whom?
• -Aware of all CP needs, resident limitations?

40
SURVEYOR MOLEARNING TO DO WHAT THEY DO

• RECORD REVIEW
• -Thorough Assessment , Re-assessment
• -Identified Thx, Texture, Assistance
• -Care plan (CP) according to resident choices
  Portion size, frequency, preferences
• -CP specific to resident needs Assistance,
  encouragement, special rehab
• -CP current Change, illness, end of life
• -Did staff consistently implement CP all shifts
• -Are order according to type and amt of feeding

41
SURVEYOR MOLEARNING TO DO WHAT THEY DO

• TOUGH SURVEYOR QUESTIONS (THEY ARE TO ASK WHEN
  NUTRITION CARE IS NOT CONSISTENT WITH STANDARDS
  OF PRACTICE OR THERE IS DECLINE)
• -What are facility systems for offering
  alternatives when there are refusals?
• -When there are NO interventions Has there been
  any identification or monitoring of risks?
• -How does facility validate effectiveness of
  interventions when there is change or decline

42
SURVEYOR FINDINGSSEVERITY ?

• Failure to provide a prescribed sodium-restricted
  therapeutic diet (unless declined by the resident
  or the residents representative or not followed
  by the resident) however, the resident did not
  experience medical complications such as heart
  failure related to sodium excess.

43
SURVEYOR FINDINGSSEVERITY ?

• Unplanned weight change and declining food and/or
  fluid intake due to the facilitys failure to
  assess the relative benefits and risks of
  restricting or downgrading diet and food
  consistency or to obtain or accommodate resident
  preferences in accepting related risks

44
SURVEYOR FINDINGS SEVERITY ?

• Continued weight loss and functional decline
  resulting from ongoing, repeated systemic failure
  to assess and address a residents nutritional
  status and needs, and implement pertinent
  interventions based on such an assessment

45
SURVEYOR FINDINGSSEVERITY ?

• A resident with known celiac disease (damage to
  the small intestine related to gluten allergy)
  develops persistent gastrointestinal symptoms
  including weight loss, chronic diarrhea, and
  vomiting, due to the facility's failure to
  provide a gluten-free diet (i.e., one free of
  wheat, barley, and rye products) as prescribed by
  the physician.
•  

46
SURVEYOR FINDINGSSEVERITY ?

• Development of life-threatening symptom(s), or
  the development or continuation of severely
  impaired nutritional status due to repeated
  failure to assist a resident who required
  assistance with meals

47
SURVEYOR FINDINGSSEVERITY ?

• Significant unplanned weight change and impaired
  wound healing (not attributable to an underlying
  medical condition) due to the facilitys failure
  to revise and/or implement the care plan to
  address the residents impaired ability to feed
  him/herself

48
SURVEYOR FINDINGSSEVERITY ?

• Failure to provide additional nourishment when
  ordered for a resident, however, the resident did
  not experience significant weight loss

49
SURVEYOR FINDINGS SEVERITY ?

• Substantial and ongoing decline in food intake
  resulting in significant unplanned weight loss
  due to dietary restrictions or downgraded diet
  textures (e.g., mechanic soft, pureed) provided
  by the facility against the residents expressed
  preferences

50
SURVEYOR FINDINGS ?

• Evidence of cardiac dysrhythmias or other changes
  in medical condition due to hyperkalemia,
  resulting from the facilitys failure to provide
  a potassium restricted therapeutic diet that was
  ordered

51
SURVEYOR FINDINGSSEVERITY ?

• Loss of weight from declining food and fluid
  intake due to the facilitys failure to assess
  and address the residents use of medications
  that affect appetite and food intake

52
SURVEYOR FINDINGSSEVERITY ?

• Decline in function related to poor food/fluid
  intake due to the facilitys failure to
  accommodate documented resident food dislikes and
  provide appropriate substitutes

53
SURVEYOR FINDINGSSEVERITY ?

• Failure to obtain accurate weight(s) and to
  verify weight(s) as needed
• Poor intake due to the facilitys intermittent
  failure to provide required assistance with
  eating, however, the resident met identified
  weight goals

54
SURVEYOR FINDINGS SEVERITY ?

• O -Resident NOT receiving snacks, recommended by
  RD
• -Not offered alternatives when refused items
• I -CNA did not know CP approaches
• -CNA concern with clamping down on spoon ,
  poor intakes
• R -Loss of 22 pounds (14 IBW)/ 7 months Severe
  
• -Lack of comprehensive assessment and CP
  (dining habits)
• -Further wt loss Lack of comprehensive
  evaluation, RD not making recommendations
  (snacks at 4th month of loss -No
  re-assessment/plan to regain loss wt, only
  stabilize
  -No
  involvement of RD in wt variance committee

55
SURVEYOR FINDINGS SEVERITY ?

• O -Poor intakes, CNA recorded higher then
  surveyor observation
• -BOOST Plus offered as ordered TID between
  meals, but only small taken, MAR is signed
  when offered without noted
• I -RD unaware that BOOST Plus not taken
• -Cooks offer only fortified cereal and super
  pudding, other residents have fortified milk
  (resident dislikes), cannot state what other
  items on fortified diet or what to substitute
• -RD has not spoken to family regarding wt loss,
  placement of tube (RD note indicates that she
  would)
• R -Lasix thx, initial wt loss of 5 in3 months,
  then continues to loose 2/months for 4 more
  months to below IBW 94-116
• -RD charts monthly stating wt loss due to lasix
  thx, no new interventions
• -RD notes state she will speak to family
  regarding wt loss/tube placement, no
  documentation of this

56
SURVEYOR FINDINGSSEVERITY ?

• O -Alternatives when food was refused Resident
  Not consistently offered
• - of Meal Eaten Policy Not consistently
  followed
• I -CNA unsure of how to document nourishments
• R -Plan of Care (At Risk for Nutrition
  Decline)Not updated when past interventions
  ineffective
• -Resident lost 7.8 lbs or 5 body weight
  (unintended)/1 month Not referred to R.D.,
  untimely
• - Wt Variance Committee recommendation for 2
  Cal Med Pass 2 oz TID No documentation of
  follow up, Not implemented

57
WHAT IS THE SCOPE/SEVERITY?

• O-Meal acceptance varied between 30-50
• -Resident decline in fdg ability, no restorative
  program
• I -No adjustments to meal pattern or
  nourishments until after 6 months of
  insignificant, unintended wt loss
• -IDT not able to identify what and when
  interventions are to be done when risk identified
• R-Slow weight loss of 8 in six months, RD
  charted as insignificant, no recommendations
  until after 6 months
• -CP identified resident at risk due to
  diagnoses variable intake
• -Meal acceptance fluctuate with intake often
  poor

58
Deficiency CategorizationKey elements for
Severity Determination for Tag F371 pg. 24 Adv
Copy

• 1. Presence of harm/negative outcome(s) or
  potential for negative outcomes because of the
  presence of unsanitary conditions.
• Foodborne illness or
• Ingestion or potential ingestion of food that
  was not procured from approved sources, and
  stored, prepared, distributed or served under
  conditions

59
Key elements for Severity Determination for Tag
F371
2. Degree of harm (actual or potential) related
to the noncompliance. Identify how the facilitys
noncompliance caused, resulted in, allowed or
contributed to the actual or potential for harm.

• 2. Degree of harm (actual or potential) related
  to the noncompliance. Identify how the facilitys
  noncompliance caused, resulted in, allowed or
  contributed to the actual or potential for harm.
• If harm Determine level of serious injury,
  impairment, death, or discomfort
• If harm has not yet occurred Determine the
  potential (above)

60
Key elements for Severity Determination for Tag
F371

• 3. The immediacy of correction required.
  Determine whether the noncompliance requires
  immediate correction in order to prevent (above)
  harm to one or more residents
• Survey Team
• Evaluate the harm or potential for harm based
  upon levels of severity
• First, R/O Level 4, Immediate Jeopardy
  Immediacy, Culpability, and Severity

61
Severity Level 4 Considerations Immediate
Jeopardy to Resident Health or Safety

• Has allowed/caused/resulted in or is likely to
  allow/cause/result in serious injury, harm,
  impairment, or death to a resident and
• Requires immediate correction, as the facility
  either created the situation or allowed the
  situation to continue by failing to implement
  preventive or corrective measures

62
Severity Level 3 Considerations Actual Harm that
is Not Immediate Jeopardy

• 3 indicates noncompliance that results in actual
  harm that is not immediate jeopardy. The negative
  outcome can include but may not be limited to
  clinical compromise, decline, or the residents
  inability to maintain and/or reach his/her
  highest practicable level of well-being.
  Therefore, a Level 3 deficiency is indicated when
  unsafe food handling and inadequate sanitary
  conditions result in actual harm to residents

63
Severity Level 2 Considerations No Actual Harm
with Potential for More Than Minimal Harm that is
Not I J

• resident outcome of no more than minimal
  discomfort and/or has the potential to compromise
  the resident's ability to maintain or reach his
  or her highest practicable level of well being.
  The potential exists for greater harm to occur if
  interventions are not provided.
• As a result of the facilitys noncompliance, the
  potential for food contamination and/or growth of
  pathogenic microorganisms exists.

64
Severity Level 1 Considerations No Actual Harm
with Potential for Minimal Harm

• The failure of the facility to procure, prepare,
  store, distribute and handle food under sanitary
  conditions places this highly susceptible
  population at risk for more than minimal harm.
  Therefore, Severity Level 1 does not apply for
  this regulatory requirement
•  

65
SURVEYOR FINDING SEVERITY ?

• Upon inquiry by the surveyor, the food service
  workers tested the sanitizer of the dish machine,
  the chemical rinse of the pot-and-pan sink, and a
  stationary bucket used for wiping cloths. The
  facility used chlorine as the sanitizer. The
  sanitizer tested less than 50 ppm in all three
  locations. Staff interviewed stated they were
  unaware of the amount of sanitizer to use and the
  manufacturers recommendations to maintain the
  appropriate ppm of available sanitizer.

66
SURVEYOR FINDINGS SEVERITY ?

• The facility purchased both unpasteurized shell
  eggs and regular shell eggs for all cooking
  purposes. The cook prepared and served
  sunny-side-up eggs with barely cooked yolks
  (i.e., not cooked to at least 145 degrees F for
  at least 15 seconds) for fourteen residents
  breakfasts. Using unpasteurized, shell eggs to
  prepare undercooked eggs for eating increased the
  risk of residents being infected with Salmonella,
  which could lead to a life-threatening illness.
  The facility did not have a system in place to
  minimize foodborne illness in the preparation of
  undercooked unpasteurized eggs.

67
SURVEYOR FINDINGS SEVERITY ?

• Outbreak of nausea and vomiting occurs in the
  facility related to the inadequate sanitizing of
  dishes and utensils

68
SURVEYOR FINDING SEVERITY?

• O 7 AM Two large roasts, cut in two, cooling in
  walk in refrigerator, cooked day before 50
  degrees F
• I Cook took roasts out at 4 PM before dinner
  tray line. Clocked out at 7 PM.
• Cook cannot verbalize the safe timeframes for
  cool down through warm danger zone
• R Cool down log has limited documentation on
  cool downs. No recent inservices

69
SURVEYOR FINDING SEVERITY?

• O Five cases of thawed "Mighty Shakes in
  walk-in refrigerator NOT dated
• I Cook does not know when these were put in the
  walk-in. They use two cases a week. Never date
• R Product label states that once thawed use
  with-in 14 days, No P P

70
SURVEYOR FINDING SEVERITY?

• O Paper towel wipe test (up under roof)
  indicates ice machine bin has not been thoroughly
  cleaned
• I Dietary does not clean ice bin, only
  sanitizes it. Maintenance services internal
  components, does not regularly clean or sanitize,
  never seen manufacturers guidance
• R P P on ice machine

71
MAY YOU FIND THE FINDINGS BEFORE THE SURVEYORS
DO WELL ON SURVEYS!!
72
Facility Office Paperwork
73
CDRs

• CDR Consultant Dietitian Report
• Hours worked are to be filled out each visit. Do
  NOT put just 8 hours, use time in/time out e.g.,
  800 400 pm. Date correctly with month, day
  and year.
• Hours worked must equal hours paid to consultant.
  Hours paid to consultant must be the same as the
  hours on the CDR. All these hours are ultimately
  used to bill the facility. If the contract hours
  are for 8 and you worked 10 there needs to be
  approval by the facility administrator and a
  brief explanation e.g., in-service, survey etc.
• At the end of the month, or last visit to
  facility, the CDR needs to be faxed into
  Nutrition Inks office.