Conquering Weight Loss
Transcript of Conquering Weight Loss
7/6/2021
1
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
1
2
7/6/2021
2
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
This Photo by Unknown Author is licensed under CC BY-NC-ND
3
4
7/6/2021
3
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
5
6
7/6/2021
4
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?
7
8
7/6/2021
5
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
This Photo by Unknown Author is licensed under CC BY
9
10
7/6/2021
6
Risk Factors That Contribute to UWL
Chewing problem
Swallowing problem
Impaired mobility
Dehydration
Pressure ulcers/nonhealing wounds
Hip fractures
Infection
This Photo by Unknown Author is licensed under CC BY-NC-ND
Risk Factors That Contribute to UWL
Depression
Dementia
Confusion
Social isolation
Anxiety
Bereavement
This Photo by Unknown Author is licensed under CC BY-SA-NC
11
12
7/6/2021
7
Risk Factors That Contribute to UWL
Polypharmacy Drugs interact with one another and
different foods
Causes side effects:
N/V
Anorexia
Sensory losses
This Photo by Unknown Author is licensed under CC BY
Medications That Potentially Lead to Weight Loss
13
14
7/6/2021
8
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
This Photo by Unknown Author is licensed under CC BY-NC-ND
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
This Photo by Unknown Author is licensed under CC BY-SA
15
16
7/6/2021
9
17
18
7/6/2021
10
19
20
7/6/2021
11
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
This Photo by Unknown Author is licensed under CC BY-SA
21
22
7/6/2021
12
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
23
24
7/6/2021
13
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
This Photo by Unknown Author is licensed under CC BY-NC-ND
25
26
7/6/2021
14
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
This Photo by Unknown Author is licensed under CC BY-NC-ND
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
27
28
7/6/2021
15
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
This Photo by Unknown Author is licensed under CC BY
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
29
30
7/6/2021
16
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
This Photo by Unknown Author is licensed under CC BY-SA-NC
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
31
32
7/6/2021
17
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
This Photo by Unknown Author is licensed under CC BY-NC-ND
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
33
34
7/6/2021
18
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
This Photo by Unknown Author is licensed under CC BY-NC-ND
35
36
7/6/2021
19
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).
37
38
7/6/2021
20
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
39
40
7/6/2021
21
Does my facility policy/process meet CMS expectations for obtaining weights?
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%
41
42
7/6/2021
22
How to Calculate Loss
% of body weight loss =. Weight Loss
____________ x 100
Original Weight
Case Study Questions
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?
43
44
7/6/2021
23
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
This Photo by Unknown Author is licensed under CC BY-SA
45
46
7/6/2021
24
Does my facility policy/process meet CMS expectations for obtaining weights?
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
This Photo by Unknown Author is licensed under CC BY-NC
47
48
7/6/2021
25
Does my facility policy/process meet CMS expectations for obtaining weights?
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)
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 Categorization
This Photo by Unknown Author is licensed under CC BY
49
50
7/6/2021
26
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
This Photo by Unknown Author is licensed under CC BY-SA
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
This Photo by Unknown Author is licensed under CC BY-NC-ND
51
52
7/6/2021
27
Case Study Questions
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
This Photo by Unknown Author is licensed under CC BY-NC
53
54
7/6/2021
28
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 Categorization
This Photo by Unknown Author is licensed under CC BY
Case Study Questions
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?
55
56
7/6/2021
29
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
This Photo by Unknown Author is licensed under CC BY
57
58
7/6/2021
30
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
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
59
60
7/6/2021
31
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 : 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
This Photo by Unknown Author is licensed under CC BY-SA
61
62
7/6/2021
32
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
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
63
64
7/6/2021
33
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 : 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
65
66
7/6/2021
34
F692 : InterventionsFunctional Factors
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
F692 : InterventionsFunctional Factors
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
This Photo by Unknown Author is licensed under CC BY
67
68
7/6/2021
35
F692 : InterventionsFunctional Factors
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
This Photo by Unknown Author is licensed under CC BY-NC
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
69
70
7/6/2021
36
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
F692 : InterventionsFood Intake
Fortify Foods
Offer Small More Frequent Meals
Provide between – meal snacks and nourishments
Increase portion size of favorite foods and meals
Provide Nutritional Supplements
This Photo by Unknown Author is licensed under CC BY-SA
71
72
7/6/2021
37
F692 : InterventionsFood Intake
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
This Photo by Unknown Author is licensed under CC BY-NC
This Photo by Unknown Author is licensed under CC BY-NC-ND
This Photo by Unknown Author is licensed under CC BY-SA-NC
73
74
7/6/2021
38
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
F692 : InterventionsFood Intake
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”
This Photo by Unknown Author is licensed under CC BY-SA-NC
75
76
7/6/2021
39
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 : 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
77
78
7/6/2021
40
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
This Photo by Unknown Author is licensed under CC BY-NC-ND
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
This Photo by Unknown Author is licensed under CC BY-SA
This Photo by Unknown Author is licensed under CC BY-SA
79
80
7/6/2021
41
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: 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.
This Photo by Unknown Author is licensed under CC BY-NC-ND
81
82
7/6/2021
42
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: 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
83
84
7/6/2021
43
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: 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
This Photo by Unknown Author is licensed under CC BY
85
86
7/6/2021
44
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 Categorization
This Photo by Unknown Author is licensed under CC BY
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
87
88
7/6/2021
45
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 Categorization
This Photo by Unknown Author is licensed under CC BY
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
89
90
7/6/2021
46
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 Categorization
This Photo by Unknown Author is licensed under CC BY
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
This Photo by Unknown Author is licensed under CC BY-NC-ND
91
92
7/6/2021
47
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:
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
F692-Elements of Noncompliance
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
This Photo by Unknown Author is licensed under CC BY-SA
This Photo by Unknown Author is licensed under CC BY
93
94
7/6/2021
48
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
F692-Elements of Noncompliance: Severity Level 4 Examples
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
95
96
7/6/2021
49
F692-Elements of Noncompliance: Severity Level 4 Examples
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
97
98
7/6/2021
50
•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)
F692-Elements of Noncompliance: Severity Level 3 Examples
F692-Elements of Noncompliance: Severity Level 3 Examples
•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
This Photo by Unknown Author is licensed under CC BY
99
100
7/6/2021
51
F692-Elements of Noncompliance: Severity Level 3 Examples
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
F692-Elements of Noncompliance: Severity Level 3 Examples
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
This Photo by Unknown Author is licensed under CC BY-NC-ND
101
102
7/6/2021
52
F692-Elements of Noncompliance: Severity Level 2 Examples
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.
F692-Elements of Noncompliance: Severity Level 2 Examples
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
This Photo by Unknown Author is licensed under CC BY-SA
103
104
7/6/2021
53
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
This Photo by Unknown Author is licensed under CC BY-SA-NC
105
106
7/6/2021
54
Case Study Questions
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
This Photo by Unknown Author is licensed under CC BY-NC
107
108
7/6/2021
55
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
This Photo by Unknown Author is licensed under CC BY
Case Study Review
This Photo by Unknown Author is licensed under CC BY-NC
109
110
7/6/2021
56
This Photo by Unknown Author is licensed under CC BY
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
111
112