Conquering Weight Loss

7/6/2021

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Conquering Weight LossEllen Turk RD,LD

Outline

Definition of unintended weight loss and why we care

Risk factors

CMS - Nutrition Critical Element Pathway

F692 regulation review

Tips for obtaining accurate weights

Interventions for unintended weight loss

My resident had unintentional weight loss, now what?

Note: Case study and associated questions will be discussed throughout the presentation

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Unintended Weight Loss

• Also known as involuntary weight loss

• Definition: a decrease in body weight that is not planned or desired

• Occurs in up to 15-20% of older adults

• Insidious weight loss: gradual, unintended, progressive weight loss over time

This Photo by Unknown Author is licensed under CC BY-NC-ND

Why Do We Care about Unintended Weight Loss?

Associated with poor clinical outcomes including: Increased morbidity

Increased mortality

Functional decline in Activities of daily living

Increased infections

Pressure ulcers


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http://patymsnutritionworld.blogspot.com/2011_09_01_archive.html

https://creativecommons.org/licenses/by-nc-nd/3.0/

http://escuela25del12.blogspot.com/


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Case Study

Phyllis, an 82 YO Female is a resident at a local skilled nursing facility

Current Diagnosis Include: COPD, respiratory failure, fall with humerus fracture, DM, HTN, GERD, CKD

Current Medications: Aspirin, Albuterol, Metformin, Oxycodone, Memantine, Zofran PRN

Recently has experienced decreased functional mobility

Recent lab values: Hgb 8.1, Hct 30.2, glucose 152, albumin 2.8

Case Study

Per skin assessment: Stage 2 pressure ulcer to sacrum 2.0 x 1.5 cm

Current diet: RCS/regular texture/thin liquids

Meal intakes x 1 week B: 34%, L: 51% , D 49%

Admit weight: 145#

During resident interview Phyllis reported:

Chewing problem r/t dentures no longer fitting

Decreased appetite

Husband recently passing away

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Case Study

Phyllis’s Weight: 03/03/2020 145#

03/10/2020: 144#

03/17/2020: 137#

03/24/2020: 139#

03/31/2020: 137#

04/02/2020: 140#

05/03/2020: 135#

06/01/2020: 130#

07/01/2020: 132#

08/04/2020: 137#

09/02/2020: 140#

Case Study Questions

1. List 3 risk factors Phyllis has for unintended weight loss

2. True or False: Polypharmacy can contribute to unintended weight loss?

3. True or False? As we age, basal metabolic rate decreases by 5% each decade of life?

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Risk Factors That Contribute to Unintended Weight Loss

As we age physiological changes in our body lead to changes in taste and smell and a decrease in basal metabolic rate of 2% with each decade of life

Changes in hormone levels that control hunger and fullness

Per the Academy of Nutrition and Dietetics, “By an estimate 50 to 70 percent of residents in nursing homes leave > 25% of their food uneaten at most meals and 60 to 80 percent of residents have an order to receive dietary supplements”

This Photo by Unknown Author is licensed under CC BY

Risk Factors That Contribute To UWL

Kidney disease

Congestive Heart Failure

Diabetes Mellitus

Parkinson’s

CVA

COPD

Rheumatoid Arthritis

Multiple Sclerosis

ALS

Cancer

GI disorders (Crohn’s , pancreatitis, colitis)

This Photo by Unknown Author is licensed under CC BY-SA-NC

This Photo by Unknown Author is licensed under CC BY-SA


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http://www.freefoodphotos.com/imagelibrary/meals/slides/homemade_dinner.html

https://creativecommons.org/licenses/by/3.0/

https://tscpl.org/health/diabetes

https://creativecommons.org/licenses/by-nc-sa/3.0/

https://commons.wikimedia.org/wiki/File:201405_kidney.png

https://creativecommons.org/licenses/by-sa/3.0/

http://www.the-vital-edge.com/technology-ecology/


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Risk Factors That Contribute to UWL

Chewing problem

Swallowing problem

Impaired mobility

Dehydration

Pressure ulcers/nonhealing wounds

Hip fractures

Infection



Depression

Dementia

Confusion

Social isolation

Anxiety

Bereavement


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http://chillopedia.com/interesting/top-5-common-myths-about-dehydration/


http://geriatricsforcaregivers.net/how-to-diagnose-dementia-the-basics/


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Polypharmacy Drugs interact with one another and

different foods

Causes side effects:

N/V

Anorexia

Sensory losses


Medications That Potentially Lead to Weight Loss

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http://edelweisspublications.com/keyword/33/1372/Drug-evaluation


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Weight Loss and Covid19

Study published in JAMDA evaluated a 193 residents in a skilled nursing facility

Over a 3 month period, Older adults on average weighed 3.68 lb. less after the implementation of nursing home covid19 visitor and isolation restrictions

Recent JAMA from April 2021 evaluated 97 patients who had acute smell loss with diagnosis of covid19

45.1% regained full recovery of olfaction after 4 months

96.1% regained full recovery of olfaction after 12 months


How Does Weight Loss Relate to CMS and Your Facility?

Weight loss is coded on the MDS Section K

Weight loss is looked at as part of the Nutrition Critical Element Pathway during survey

Pathway surveyors will use to determine if facility practices are in place to identify, evaluate and start interventions to prevent maintain or improve the residents’ nutritional status


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https://en.wikipedia.org/wiki/Medicare_Part_D


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How Does Weight Loss Relate to CMS and Your Facility?

If facility fails to maintain acceptable parameters of nutritional status (including weight) it can result in a survey citation

F692 Tag


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https://en.wikipedia.org/wiki/Medicare_Part_D


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Does anyone have experience with an F692 citation and weight loss that they would be willing to share?

Regulation Review– F692: Nutrition and Hydration

• (Includes and gastrostomy tubes, PEG and PEJ and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident:

• Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise

• Is offered sufficient fluid intake to maintain proper hydration and health

• Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet

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F692 Regulation Review: Nutrition and Hydration Status

• Regulation is divided into sections

• Intent• Definitions

• Guidance

• Assessment

• Care Planning

• Interventions

• Monitoring

• Investigative Protocol

• Key Elements of Noncompliance

• Deficiency CategorizationThis Photo by Unknown Author is licensed under CC BY

F692- Intent of Regulation

The intent of this requirement is that the resident maintains, to the extent possible, acceptable parameters of nutritional and hydration status and that the facility:

Provides nutritional and hydration care and services to each resident, consistent with the resident’s comprehensive assessment


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http://2012.igem.org/Team:Calgary/Project/HumanPractices/Killswitch/Regulation


https://counterinformation.wordpress.com/2019/03/01/brexit-the-implications-for-health-and-social-care/


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F692- Intent of Regulation

Recognizes, evaluates, and addresses the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration

Provides a therapeutic diet that takes into account the resident’s clinical condition, and preferences, when there is a nutritional indication




• Intent

• Definitions

• Guidance• Assessment

• Care Planning

• Interventions

• Monitoring




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F692 :Guidance

• Early identification of residents with , or at risk for, impaired nutrition or hydration status may allow the interdisciplinary team to develop and implement interventions to stabilize or improve nutritional status before complications arise

• Body weight and laboratory results can be stabilized or improved with time, but may not be correctable in some Individuals

• Intake alone is not the only factor that can affect nutritional status


F692: Guidance

Many factors can influence weight and nutritional status as one ages

The body may not absorb or use nutrients as effectively

There may be changes in the ability to taste food or there may be a decreased sensation for thirst or hunger

The resident’s medical condition can also affect how well they maintain weight, such as changes in muscle mass , cognitive status , nearing end of life, or a disease process, such as kidney disease or congestive heart failure, which may cause the resident to retain fluids in the bodyThis Photo by Unknown Author is licensed under CC BY-SA

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http://www.emptycagesdesign.org/eat-2017-a-whole-bunch-of-exciting-courses-happening-this-year/


http://www.progressive-charlestown.com/2018/11/plant-based-or-vegan-diet-may-be-best.html


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F692 : Guidance

Failure to identify residents at risk for compromised nutrition and hydration may be associated with an increased risk of mortality and other negative outcomes

Impairment of anticipated wound healing

Decline in function

Fluid and electrolyte imbalance/dehydration

Unplanned weight change


F692 : Guidance

• A systematic approach can help staff’s efforts to optimize a resident’s nutritional status. This process includes:

• Identifying and assessing each resident’s nutritional status and risk factors

• Evaluating/analyzing the assessment information

• Developing and consistently implementing pertinent approaches

• Monitoring the effectiveness of interventions

• Revising interventions as necessary

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http://www.markwk.com/2016/11/tracking-hydration-water.html


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F692: Guidance

Weight loss, poor nutritional status, or dehydration should be considered avoidable unless the facility can prove it has assessed/reassessed the resident’s needs, consistently implemented related care planned interventions, monitored for effectiveness, and ensured coordination of care among the interdisciplinary team




• Intent

• Definitions

• Guidance

• Assessment• Care Planning

• Interventions

• Monitoring




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https://zorgenvoormijnmoeder.blogspot.com/2006_07_01_archive.html




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F692 : Assessment

A comprehensive nutritional assessment should be completed on any resident identified as being at risk for unplanned weight loss/gain and/or compromised nutritional status

Through a comprehensive nutritional assessment, the interdisciplinary team clarifies nutritional issues, needs, and goals in the context of the resident’s overall condition

Assessment must be completed by an RD

Out of scope of practice for CDM to “Assess” This Photo by Unknown Author is licensed under CC BY

F692: Assessment

Completion of the RAI does not remove the facility’s responsibility to document a more detailed resident assessment

The assessment should identify those factors that place the resident at risk for inadequate nutrition/hydration


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http://www.knowthymoney.com/2014/12/a-conversation-with-dietitician.html


http://www.gbcnv.edu/assessment/


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F692: What should my Nutrition Assessment Include?

The nutritional assessment may include the following information: General appearance

Nutrition focused physical exam Height Weight

Including usual body weight Interviews with key staff members Food and fluid Intake

Estimate of calorie, nutrient and fluid needs and whether intake is adequate to meet needs

Route of intake, snack patterns, food preferences, portion sizes Fluid loss or retention Laboratory values

This Photo by Unknown Author is licensed under CC BY-NC

F692: What should my Nutrition Assessment Include?

Altered Nutrient intake, absorption, and utilization Cognitive function or decline

Difficulty with chewing or swallowing food

An inadequate amount of food or fluid, including insufficient tube feedings

Dining environment

Feeding ability

Adverse consequences related to medications

Diseases and conditions such as cancer, diabetes mellitus, advanced or uncontrolled heart or lung disease, infection and fever, liver disease, kidney disease, hyperthyroidism, mood disorders, gastrointestinal disorders, pressure injuries or other wounds, and repetitive movement disorders (e.g., wandering, pacing, or rocking).

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Case StudyQuestions

3. True or False: Best practice per CMS is for the facility to obtain Phyllis’s weight 4x per year

4. True or False: 7.5% weight loss in 6 months is considered significant?

Does my facility policy/process meet CMS expectations for obtaining weights?

Per F692 - Current standards of practice recommend for facilities to obtain a resident’s weight:

On admission/readmission

Weekly for the first 4 weeks upon admission

At least monthly thereafter

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Additional circumstances may warrant more frequent weights Significant change in condition

Persistent decline in food intake

Alteration in fluid/electrolyte imbalance

Weights may not be appropriate in individuals who are terminally ill or request comfort care

If a weight cannot be obtained or a resident refuses, alternate methods can be used to track

I.E. Midarm circumference

CMS Definition of Unintended Weight Loss

Interval Significant Loss Severe Loss

1 Month 5% Greater than 5%

3 Months 7.5% Greater than 7.5%

6 Months 10% Greater than 10%

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How to Calculate Loss

% of body weight loss =. Weight Loss

____________ x 100

Original Weight


Phyllis’s Weight:

03/03/2020 145#

03/10/2020: 144#

03/17/2020: 137#

03/24/2020: 139#

03/31/2020: 137#

04/02/2020: 140#

05/03/2020: 135#

06/01/2020: 130#

07/01/2020: 132#

08/04/2020: 137#

09/02/2020: 140#

5. Calculate % weight loss at 1 month, 3 months and 6 months

6. Did Phyllis have significant weight loss at 1 month? 3 months? 6 months?

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Consider patients mobility and clinical condition when selecting method to obtain weight

Standing scales

Chair scales

Wheelchair scales

Hoist scales

Bed scales

Use a consistent scale for obtaining weights

Have a consistent staff member obtain weights

Weigh at the same time each month and same time of day

Balance scale to zero before and after each weight

Tips for Obtaining Accurate Weights

Tips for Obtaining Accurate Weights

Weigh patients in same clothing if possible ( light clothing preferred) , no shoes

Empty catheter bags and drainage devices prior to weighing

If possible, remove prosthetic devices or weigh the prosthetic device individually and subtract from total body weight

Remove pillows, purses, jackets etc.

Calibrate scale per manufacturer's instructions

Immediately record weight

Follow appropriate infection control practices


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http://www.investitwisely.com/living-to-100-and-beyond-how-will-it-affect-your-retirement-plans/


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Have procedure in place for tracking weight changes to identify significant weight loss

Identify weight loss at 5% in one month,7.5% in 3 months and 10% in 6 months

Have a policy and procedure in place for how your facility obtains weights


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http://www.pngall.com/weight-scale-png


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Per CMS Regulations , there should be a documented clinical basis for any conclusion that nutritional status or significant weight change are unlikely to stabilize or improve (e.g. physician’s documentation as to why weight loss is medically unavoidable)



• Intent

• Definitions

• Guidance

• Assessment

• Care Planning• Interventions

• Monitoring



• Deficiency Categorization


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F692: Care Planning

Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident’s specific nutritional concerns and preferences

Consult Advanced Directives if necessary Note: DNR does not indicate a resident is declining other

appropriate treatments or services. It only indicates that the resident has chosen to be resuscitated if cardiopulmonary functions cease


F692: Care Planning

• The care plan must address, to the extent possible, identified causes of impaired nutritional status, reflect the resident’s personal goals and preferences, and identify resident-specific interventions and a time frame and parameters for monitoring

• Goals should be measurable


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https://en.wikipedia.org/wiki/File:Preference_example.jpg


https://www.europeanhydrationinstitute.org/hydration_and_diet/


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7. Identify 2 possible root causes for Phyllis’s uintended weight loss

8. Identify 1 care plan goal for Phyllis’s unintended weight loss

F692: Care Planning

Examples of care plan goals may include, but are not limited to:

A target weight range

Desired fluid intake

The management of an underlying medical condition (e.g. diabetes, kidney disease, wound healing, heart failure, or infection)

The prevention of unintended weight loss or gain


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• Intent

• Definitions

• Guidance

• Assessment

• Care Planning

• Interventions• Monitoring






9. List 3 Possible Interventions for Phyllis’s Unintended Weight Loss

10. True or False: A resident may experience a decline in his or her ability to chew food. If the underlying cause is poorly fitting dentures that are causing pain or are loose in the mouth, the intervention of modifying the food texture would not address the primary cause?

11. True or False: There is strong evidence to support the MD prescribing Phyllis an appetite stimulant?

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F 692: Interventions for Unintended Weight Loss

Interventions related to a resident’s nutritional status must be individualized to address the specific needs of the resident. Examples of care plan development considerations can include, but are not limited to:

Diet Liberalization Weight Related Interventions

Environmental Factors

Disease Process

Functional Factors

Food Intake

Medications

Maintaining Fluid and Electrolyte Balance

Feeding Tubes

TPN

F692 : InterventionsDiet Liberalization

• Minimize restrictions

• Provide preferred foods prior to supplements

• It is the responsibility of the facility to:• Talk with the resident, their family and representative

(whenever possible) and provide information pertaining to the risks and benefits of a liberalized diet

• Work with the resident’s physician and other nursing home professionals (dietary manager, nurses, speech therapists, etc.), using the care planning process, to determine the best plan for the resident

• Accommodate the resident’s needs, preferences, and goals


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Diet Liberalization

Weight Related Interventions Environmental Factors

Disease Process

Functional Factors

Food Intake

Medications


Feeding Tubes

TPN

For residents with unplanned weight loss, the care plan should include nutritional interventions to address the underlying risks and causes based on the comprehensive or any subsequent nutritional assessment

The development of these interventions should involve the resident and/or the resident representative to ensure the resident’s needs, preferences and goals are accommodated.

F692 : InterventionsWeight Related Interventions

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Diet Liberalization

Weight Related Interventions

Environmental Factors Disease Process

Functional Factors

Food Intake

Medications


Feeding Tubes

TPN

F692 : InterventionsEnvironmental Factors

Consider the aroma, flavor, form and appearance of food

Provide pleasant dining experience

Flexible dining schedules and meal times

Provide palatable, attractive, nutritious meals

Use seasonings, serve foods at proper temperatures

Ensure dining room and resident’s rooms are appropriate for dining


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Diet Liberalization



Disease Process Functional Factors

Food Intake

Medications


Feeding Tubes

TPN

A resident’s clinical condition may have a significant impact on the types of interventions considered. The facility is responsible for identifying relevant diagnoses (e.g. wound healing, anorexia, end-of-life, etc.) and appropriate interventions to address specific needs, as applicable

F692 : InterventionsDisease Process

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Diet Liberalization



Disease Process

Functional Factors Food Intake

Medications


Feeding Tubes

TPN

F692 : InterventionsFunctional Factors

Functional Factors: Conditions that interfere with resident’s ability to physically perform the task of eating or drinking

Ability to use hands

Chewing problem

Swallowing problem

Ability to reposition oneself at a table This Photo by Unknown Author is licensed under CC BY-ND

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https://creativecommons.org/licenses/by-nd/3.0/

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Assess underlying cause to identify which interventions may be most effective

Example: a resident may experience a decline in his or her ability to chew food. If the underlying cause is poorly fitting dentures that are causing pain or are loose in the mouth, the intervention of modifying the food texture would not address the primary cause


Functional Factor Interventions Include: Adaptive equipment

Glasses

Hearing aides

Ensuring dentures are securely placed

Restorative eating program

Meal assistance

Ensuring food and drinks are easily accessible


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https://peerj.com/articles/1667/


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Modify diet texture if appropriate

Modified texture may unnecessarily decrease quality of life and impair nutritional status by affecting appetite and reducing intake

Identification of a swallowing abnormality alone does not necessarily warrant dietary restrictions or food texture modifications. No interventions consistently prevent aspiration and no tests consistently predict who will develop aspiration pneumonia

For example, tube feeding may be associated with aspiration, and is not necessarily a desirable alternative to allowing oral intake, even if some swallowing abnormalities are present

https://www.google.com/search?q=puree+food&sxsrf=ALeKk00P4VPWQZfxlVfgRlaoYA1H5eq8ig:1625058004758&source=lnms&tbm=isch&sa=X&ved=2ahUKEwj98PLotL_xAhXSgGoFHex0Ad4Q_AUoAXoECAEQAw&biw=1011&bih=681#imgrc=aKFMbEsMYGIOoM




Diet Liberalization



Disease Process

Functional Factors

Food Intake Medications


Feeding Tubes

TPN

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F692 : InterventionsFood Intake

Whole foods preferred to nutrition supplements• If the resident is not able to eat recommended

portions at meal times, to consume between-meal snacks/nourishments, or if he/she prefers the nutritional supplement, supplements may be tried to increase calorie and nutrient intake.

• Taking a nutritional supplement during medication administration may also increase caloric intake without reducing the resident’s appetite at mealtime


Fortify Foods

Offer Small More Frequent Meals

Provide between – meal snacks and nourishments

Increase portion size of favorite foods and meals

Provide Nutritional Supplements


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http://www.pinkwhen.com/healthy-summer-snacks/


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Fortify Meals Fortified meals increase caloric density of

foods without increasing portion sizes

Add butter, mayo, peanut butter, sour cream, half and half, whipped cream, cheese sauce, protein powder , evaporated milk, gravies

Establish a policy and procedure at your facility for fortifying meals




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https://freepngimg.com/png/11218-butter-png-clipart


http://elanaspantry.com/whipped-cream-frosting/


https://tonyburgess1969.net/2016/06/22/peanut-butter/


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High Calorie/High Protein Snack Ideas

Ice Cream

Yogurt

Cottage Cheese

Smoothie

Mashed potatoes

Avocado

Pudding

Milkshakes

Leftover desserts

Cream soups

Peanut butter

Hard boiled eggs

Sandwiches

Milk and cookies

Cheese stick

Egg Salad

Tuna SaladThis Photo by Unknown Author is licensed under CC BY-NC


Provide nutritional supplements Preferable to use food first before

supplements

If possible , Liberalize diets and fortify meals prior to supplementation

Choose high calorie/high protein supplements

“Get the best bang for your buck”


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https://flickr.com/photos/nestle/5987115449


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Diet Liberalization



Disease Process

Functional Factors

Food Intake

Medications Maintaining Fluid and Electrolyte Balance

Feeding Tubes

TPN

F692 : InterventionsMedications

Medications may be helpful in improving a resident’s nutritional status. Some ways medications may help a resident can be to increase appetite, reduce acid reflux, or reduce nausea.

Some medications may have the unintended effect of impairing a resident’s nutritional or hydration status and the resident may experience a lack of appetite, nausea, dry mouth, or other unintended effects.

A resident may require frequent sips of a drink during a meal if they experience dry mouth. It may also be appropriate to consider changing, stopping, or reducing the doses of those medications as appropriate

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F692 : InterventionsMedications

• Appetite stimulants• Appetite stimulants should

not be considered as a first-line treatment for unintended weight loss in the elderly because of the lack of clear evidence of their benefit and the potential for significant medication-related side effects


Appetite Stimulants

• Side effects including blood clots, DVT, and toxic reactions with impaired renal function and increased mortality

• Should not be used for more than 12 weeks because of risk of DVT

Megestrol (Megace)

• Treats depression

• Can have sedative side effects that may lead to increased risk of falls

Mirtazapine (Remeron)

• Contains the compound THC found in marijuana

• Also approved for treatment of N/V for chemotherapy patients

Dronabinol (Marinol)

• Antihistamine

Cyproheptadine (Periactin)

Marijuana



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http://www.wikidoc.org/index.php/Megestrol


https://www.wikidoc.org/index.php/Dronabinol


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Diet Liberalization



Disease Process

Functional Factors

Food Intake

Medications

Maintaining Fluid and Electrolyte Balance Feeding Tubes

TPN

F692: Maintaining Fluid and Electrolyte Balance

Offer a variety of fluids between meals

Assist residents with drinking

Have beverages available and within reach

Evaluate medications that may place a patient at risk for dehydration

Alternate fluids, such as popsicles, gelatin, and ice cream, may also be offered

For some residents, a fluid restriction may be required to address conditions, such as edema or congestive heart failure, and may place them at greater risk for dehydration.


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http://rebelem.com/7-pediatric-hacks-for-your-ed/


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Diet Liberalization



Disease Process

Functional Factors

Food Intake

Medications


Feeding Tubes TPN

F692: Feeding Tubes

Only considered with a resident who is not able to achieve weight stabilization or other nutrition interventions have failed

Consult advance directives Per CMS: Residents with end stage dementia,

use use of a feeding tube does not necessarily extend life, prevent aspiration PNA , improve function or limit suffering

See F693 RegulationThis Photo by Unknown Author is licensed under CC BY

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Diet Liberalization



Disease Process

Functional Factors

Food Intake

Medications


Feeding Tubes

TPN

F692: TPN

This method is used when a resident cannot or should not eat or drink by mouth

A resident with TPN may require additional monitoring, such as more frequent weights, to ensure the treatment is effective.

See F694 Regulation


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• Intent

• Definitions

• Guidance

• Assessment

• Care Planning

• Interventions

• Monitoring• Investigative Protocol




F692-Monitoring

On going monitoring of care planned interventions is expected for all residents and should include but is not limited to

Interview the resident/and or representative to determine if their personal goals are met

Direct observation of the resident

Interviews with direct care staff

Review resident specific factors identified in nutrition assessment

Are they still relevant?

Have new concerns emerged?

Evaluate the care plan to determine if current interventions are being implemented and are effective

Meal monitors, weights , labs, nurses notes, MD notes

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• Intent

• Definitions

• Guidance

• Assessment

• Care Planning

• Interventions

• Monitoring

• Investigative Protocol• Key Elements of Noncompliance



F692-Investigative Protocol

Regulation instructs Surveyors to:

Briefly review the most recent comprehensive assessments, comprehensive care plan and orders to determine whether the facility has assessed, identified and addressed as appropriate, the resident’s nutritional and hydration needs. This information will guide observations and interviews to be made in order to corroborate concerns identified

Always observe for visual cues of psychosocial distress and harm

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• Intent

• Definitions

• Guidance

• Assessment

• Care Planning

• Interventions

• Monitoring


• Key Elements of Noncompliance• Deficiency Categorization


F692-Elements of Noncompliance

To cite deficient practice at F692, the surveyor's investigation will generally show that the facility failed to do one or more of the following:

Accurately and consistently assess a resident’s nutritional status on admission and as needed thereafter

Identify a resident at nutritional risk and address risk factors for impaired nutritional status, to the extent possible

Identify, implement, monitor, and modify interventions (as appropriate), consistent with the resident’s assessed needs, choices, preferences, goals, and current professional standards of practice, to maintain acceptable parameters of nutritional status


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To cite deficient practice at F692, the surveyor's investigation will generally show that the facility failed to do one or more of the following:

Notify the physician as appropriate in evaluating and managing causes of the resident’s nutritional risks and impaired nutritional status

Identify and apply relevant approaches to maintain acceptable parameters of residents’ nutritional status, including fluids

Provide a therapeutic diet when ordered

Offer sufficient fluid intake to maintain proper hydration and health


Weight loss, abnormal protein and electrolyte lab values, and dehydration are not, by themselves, sufficient to support noncompliance at F692. Additionally, a resident does not need to experience weight loss, abnormal protein levels, D or dehydration to show noncompliance



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F692-Elements of Noncompliance: Severity Level 4 Examples

Repeated, systemic failure to assess and address a resident’s nutritional status and to implement pertinent interventions based on such an assessment resulted in continued significant or severe weight loss and functional decline


Repeated failure to assist a resident who required assistance with meals and drink resulted in or made likely the development of life-threatening symptom(s), or the development or continuation of severely impaired nutritional status

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Dietary restrictions or downgraded diet textures, such as mechanical soft or pureed textures, were provided by the facility against the resident’s expressed preferences and resulted in substantial and ongoing decline in food intake resulting in significant or severe unplanned weight loss with accompanying irreversible functional decline to the point where the resident was placed on Hospice

F692-Elements of

Noncompliance: Severity Level 4

Examples

The failure to provide an ordered potassium restricted therapeutic diet resulted in evidence of cardiac dysrhythmias or other changes in medical condition due to hyperkalemia

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•The failure to revise and/or implement the care plan addressing the resident’s impaired ability to feed him/herself resulted in significant, not severe, unplanned weight change and impaired wound healing (not attributable to an underlying medical condition)



•The failure to identify a decrease in food intake, which resulted in a significant unintended weight loss from declining food and fluids, which resulted in the resident becoming weakened and unable to participate in activities of daily living


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The failure to assess the relative risks and benefits of restricting or downgrading diet and food consistency or to accommodate a resident’s choice to accept the related risk resulted in declining food/fluid intake and significant weight loss


The failure to accommodate documented resident food dislikes and preferences resulted in poor food/fluid intake and a decline in function

The failure to provide a gluten-free diet (one free of wheat, barley, and rye products) as ordered for a resident with known celiac disease (damage to the small intestine related to gluten allergy) resulted in the resident developing persistent gastrointestinal symptoms including significant, not severe, weight loss, chronic diarrhea, and occasional vomiting


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Failure to obtain accurate weight(s) and to verify weight(s) as needed

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


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

The facility’s intermittent failure to provide required assistance with eating resulted in poor intake, however, the resident met identified weight goals


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F692-Elements of Noncompliance: Severity Level 1 Example

Severity Level 1: No Actual Harm with Potential for Minimal Harm

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

Applying it to Practice: Tips for Preventing Unintended Weight Loss

Establish and follow policy and procedure for obtaining weights

Focus on resident centered approach

Frequent monitoring of weight and meal intakes

Auditing of meals to ensure food is palatable

Open communication with IDT team


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12. Your facility has identified that Phyllis had significant unintended weight loss. What do you do now?

My resident has potential unintended weight loss, what now?

Ensure Accuracy of weight Reweigh your patient per facility policy

Weight errors are common

If weight loss is found to be accurate, refer significant weight changes to Physician, RDN or Designee and Patient/Responsible party ASAP

Have set procedure with designated employees in place for timely notification


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My resident has unintended weight loss, what now?

RDN to assess/reassess patient and document

Determine underlying root causes for weight loss

Start Interventions based on identified root cause of weight loss

Individualize interventions to address resident’s specific needs and preferences

Update Care Plan

Add to high risk IDT meeting for more frequent monitoring and follow up


Case Study Review


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References

Danilovich MK, Norrick CR, Hill KC, Conroy DE. Nursing Home Resident Weight Loss During Coronavirus Disease 2019 Restrictions. J Am Med Dir Assoc. 2020;21(11):1568-1569. doi:10.1016/j.jamda.2020.08.032

Dorner B, Friedrich EK. Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings. J Acad Nutr Diet. 2018 Apr;118(4):724-735. doi: 10.1016/j.jand.2018.01.022. PMID: 29576092.

Gaddey HL, Holder K. Unintentional weight loss in older adults. Am Fam Physician. 2014 May 1;89(9):718-22. PMID: 24784334.

Gallagher-Allred C, Robinson G. Unintended Weight Loss in Older Adults: ADA Evidence- Based Practice Guidelines. Connections. https://higherlogicdownload.s3.amazonaws.com/THEACADEMY/4556f4af-bcea-4fd9-8fc9-5647e0d15658/UploadedImages/DHCC/Documents_/UWL.pdf. Published November 2011. Accessed June 24, 2021.

Niedert KC, Carlson MP. Nutrition Care of the Older Adult: a Handbook for Nutrition throughout the Continuum of Care. Chicago: Academy of Nutrition and Dietetics; 2020.

Renaud M, Thibault C, Le Normand F, et al. Clinical Outcomes for Patients With Anosmia 1 Year After COVID-19 Diagnosis. JAMA Netw Open. 2021;4(6):e2115352. doi:10.1001/jamanetworkopen.2021.15352

Stajkovic S, Aitken EM, Holroyd-Leduc J. Unintentional weight loss in older adults [published correction appears in CMAJ. 2011 May 17;183(8):935]. CMAJ. 2011;183(4):443-449. doi:10.1503/cmaj.101471

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