HOMES AND SENIORS SERVICES. APPROVAL DATE: February 2011 REVISION DATE: July 2018

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1 Page 1 of 7 POLICY: Each resident s level of nutrition and hydration risk will be identified by the Registered Dietitian during the RAI-MDS Admission Assessment and thereafter during the quarterly, significant change or annual assessment process according to the RAI-MDS timelines OBJECTIVES: To ensure that each resident s level of nutrition and hydration risk is identified on admission during the full nutrition assessment completed by the Registered Dietitian. To ensure that each residents level of nutrition and hydration risk is reassessed, on a regular basis in order to ensure that nutrition care goals and interventions are appropriate, effective and are evaluated and revised, as required. To monitor, on a regular basis (minimum yearly), the percentages of residents assessed to be at high, moderate and low nutrition and hydration risk as part of the Home s and RD s quality improvement program. PROCEDURE: 1. As part of the RAI-MDS admission nutrition assessment process, and no later than Day 14, the Registered Dietitian (RD) identifies a nutrition risk level for each resident. 2. The RD may use the Dietitians of Canada Nutrition/Hydration Risk Identification Tool to assist in the process of identifying level of risk. 3. The RD assigns a level of nutrition/hydration risk of High, Moderate or Low, depending on various indicators on the Risk Identification Tool, as well using clinical / professional judgment, to determine which level best describes the resident and what nutrition interventions are most appropriate. 4. The Nutrition and Hydration Risk Identification tool becomes part of the resident s electronic record and is updated on a regular basis.

2 Page 2 of 7 5. The RD establishes nutrition interventions for all residents based on their identified level of nutrition and hydration risk, develops an individualized Nutrition Care Plan to meet each resident s assessed needs and oversees the nutrition care for all residents. 6. The following information may further assist the RD in identifying and monitoring each resident s level of nutrition and hydration risk: High Nutrition / Hydration Risk resident experiences numerous indicators that place him/her at a high level of risk for malnutrition/dehydration or has a diagnosis of malnutrition/dehydration or where nutrition intervention is a major component of the medical treatment. Moderate Nutrition / Hydration Risk resident experiences some risk factors related to malnutrition/dehydration or resident has a diagnosis which includes nutrition intervention as a component of the medical treatment. Low Nutrition / Hydration Risk resident is considered stable, has no significant weight concerns, no recent history of needing special diet or diagnosis of malnutrition; and does not have any current medical concerns that are likely to impact on overall nutrition and hydration status or overall health outcomes. 7. Other factors to be considered when determining nutrition and hydration risk levels include concerns from family/staff, recent surgery, infection, hospitalization, change in dental status, and medical status. 8. Each indicator itself does not necessarily determine risk level risk of malnutrition and dehydration is multi-factorial. The RD assesses all factors individually to determine their overall impact on nutrition and hydration status and uses professional judgment to determine the final risk levels. 9. Each resident s level of nutrition and hydration risk level is reviewed every three months as part of the quarterly assessment process, by either the RD by or the MSS as delegated by the RD. 10. The MSS and Nursing staff are familiar with the Nutrition and Hydration Risk Identification tool and alert the RD, through the Home s referral process, whenever risk indicators change for any resident; the RD reassesses the resident s level of nutrition and hydration risk, revises the risk level as needed and updates the interventions and

3 Page 3 of 7 Nutrition Care Plan as required. (See Appendix I for additional factors to consider when identifying nutrition/hydration risk levels) 11. The RD is responsible for changing ALL nutrition / hydration risk level NUTRITION / HYDRATION RISK IDENTIFICATION TOOL Resident Name: Admission Reassess Reassess Reassess HIGH NUTRITION / HYDRATION RISK Significant weight 5% - 1 mo., 7.5% - 3 mo., 10% - 6 mo. (reweigh confirm) or <79 />130% Goal/UBW Severely underweight or BMI 19 or less (in most elderly individuals) Severely overweight or BMI > 32.1 (in most elderly individuals) Recent changes in appetite Leaves 25% or more of food uneaten at most meals Chronically / newly poor food intake of <50% at meals/snacks Chronically / newly poor fluid intake (<50% recommended daily fluid intake) and / or s/s of dehydration Active / chronic disease and/or pain and/or behavior significantly affecting intake Advancing Dementia significantly affecting intake and/or CPS of 4, 5, 6 Physical signs of malnutrition or anorexia/failure to thrive Uncontrolled Diabetes Renal disease with dialysis and / or nutrient restrictions Liver disease with nutrient restrictions Enteral feeding TPN Dysphagia, newly diagnosed or unstable GI concerns e.g. diarrhea, nausea, emesis>3 days (excluding outbreak) Decubitus ulcer 2,3,4, unstageable/ delayed wound healing / stasis ulcer with significant exudate per nursing assessment Total assistance for meals / needs extensive encouragement to eat Bedridden / severely reduced mobility / history of recurrent falls History of recurrent infections including UTIs/URIs Abnormal lab values indicative of significant nutrition risk Medications negatively affecting appetite and / or nutrient absorption /or hydration status Palliative care PPS of 30% or less; CHESS score of 4 or higher Multiple or combined diet orders Comments: MODERATE NUTRITION / HYDRATION RISK

4 Page 4 of 7 Unplanned weight (< above) or BMI or or % or % of Goal/UBW Underweight or overweight but stable for 3 months or more Food intake 51 75% at most meals/snacks History of using oral nutrition supplements / missing 1 whole food group Poor or changed fluid intake (<75% but >51%) daily fluid requirement Food allergies/food intolerances New medical diagnosis requiring dietary intervention Diagnosis of dementia with moderate effect on intake CPS of 3 Hypertension, edema, CHF, COPD Controlled diabetes mellitus Controlled renal disease Controlled liver disease Dysphagia stable, no documented incidents of coughing/choking on food/fluid in last 1/4, no pneumonias Chronically/newly occurring constipation Frequent diarrhea; diverticular disease; changed bowel habits Poor skin integrity Reduced mobility Difficulty feeding self / needs aides / limited assistance with feeding Abnormal lab values indicative of moderate nutrition risk Comments: LOW NUTRITION / HYDRATION RISK No significant weight or weight stable or weight > % goal / usual body weight or BMI Food intake> 76% at meals/snacks Fluid intake>76% recommended daily fluid requirement Regular bowel function without regular laxatives/stool softeners Eats independently or with minimal assistance / no feeding concern CPS 0, 1, 2 Medical conditions stable per MD Comments: RISK LEVEL is assessed as: RD SIGNATURE: DATE : Assessing Nutrition / Hydration Risk * The RD is responsible for assessing and reassessing nutrition / hydration risk and assigning a risk level upon admission and whenever there is a change in resident s status.

5 Page 5 of 7 High Nutrition / Hydration Risk resident experiences numerous indicators that place them at a high level of risk for malnutrition/dehydration or has a diagnosis of malnutrition/dehydration or where nutrition intervention is a major component of the medical treatment. RD establishes nutrition care plan on admission and reassesses the resident frequently (minimum quarterly), making changes to the care plan as required. Moderate Nutrition / Hydration Risk resident experiences some risk factors related to malnutrition/dehydration or residents whose diagnoses include nutrition intervention as a component of the medical treatment. RD establishes nutrition care plan on admission and reassesses the resident as required (delegating stable residents to be followed by NM/FSS as able - minimum quarterly) making changes to the care plan as required. Low Nutrition / Hydration Risk resident is considered stable by the MD, has no significant weight concerns, no recent history of needing special diet or diagnosis of malnutrition; and does not have any current medical concerns that are likely to impact on overall nutrition and hydration status or overall health outcomes. RD establishes nutrition care plan on admission and delegates monitoring of residents to NM/FSS as able (minimum quarterly). Reassessing Risk Levels: * Note: This tool has been revised to reflect RAI-MDS coding terminology. RD reassesses the nutrition / hydration risk level using this tool whenever there has been a change in resident s condition. Every three months, nutrition / hydration risk level is reviewed as part of the RAI-MDS quarterly assessment; if the resident s condition is stable and indicators have remained stable, the level of nutrition / hydration risk remains the same. A residents level of nutrition and hydration risk can change quickly processes must be in place to inform the RD whenever there are health changes/status changes so that the nutrition risk level can be reassessed. Care plans must be updated whenever there is a change in a resident s nutrition / hydration risk level care plans must indicate current nutrition risk level. Other Factors Affecting Nutrition / Hydration Risk Level: Other indicators that need to be addressed when determining nutrition and hydration risk levels include - concerns from family/staff, recent surgery, infection, hospitalization, change in dental status, medical status, etc. RD assesses all factors individually to determine their overall impact on nutrition and hydration status. Final Determination of Nutrition / Hydration Risk Level: Each indicator by itself does not necessarily determine risk level risk of malnutrition and dehydration is multi factorial.

6 Page 6 of 7 RD must use professional judgment to determine final risk level and re-evaluate risk levels whenever resident s status changes. Determining Healthy Weight Ranges: Healthy weight ranges: BMI considered healthy weight for most elderly BMI < 19 and > 30 may be associated with health problems in some elderly References: ADA/DC Manual of Clinical Dietetics Nutritional Assessment of Residents in Long-Term care Facilities: Recommendations of the task force on nutrition and ageing of the IAGG European region and the IANA, The Journal of Nutrition, Health & Aging, 2009, 13(6). Nutritional Management in Long-Term Care: Development of a Clinical Guideline by Thomas, D., Ashmen, W, Morley, J., & Evans, W, Journal of Gerontology, 2000, 55 (12), M The Association between Nutritional Risk and Falls among the Frail Elderly by CS Johnson. Journal of Nutrition, Health and Aging, 2003, 7(4): BMI must be taken into consideration with other weight parameters height and weight tables for the elderly, weight changes, usual versus ideal adult body weights, ethnic differences. Use of Usual Body Weight is the most important factor in assessing weight changes Additional References: Average Weight (kg) for Height for Ages years, Master, Laser, Beckman, 1960 NHANES BMI men, NHANES BMI women Palliative Performance Scale (PPS) Victoria Hospice Society, PPS v2. Cognitive Performance Scale (CPS) Source: Morris JN, Fries BE, Mehr DR, Hawes C, Philips C, Mor V, Lipsitz L MDS Cognitive Performance Scale. Journal of Gerontology: Medical Sciences 49(4): M174 M182. Barker Blagrave & Associates Dietetics Professional Corporation Revised May 2015 Long Term Care Action Group, Dietitians of Canada Revised June 2009 and Reviewed May 2015 Appendix 1 The following information may assist the RD in determining the nutrition/hydration risk levels for residents: Risk factors associated with poor nutritional status are Inappropriate food and fluid intake Poverty Social isolation Dependency /disability Acute/chronic disease or conditions Chronic medications use Advanced age

7 Page 7 of 7 Primary and more quantifiable indicators, indicative of poor nutrition status are: Significant weight loss Significant low or high weight for height Significant reduction in serum albumin Significant or inappropriate food and fluid intake Significant reduction in mid arm circumference Significant increase or decrease in skin folds Selected nutritionally related disorders (refer to page 2) Secondary and less quantifiable indicators that have been linked to poor nutrition status, especially when they co-exist, are: Concurrent syndromes (e.g. alcoholism, cognitive impairment, chronic renal insufficiency, multiple concurrent medications, malabsorption syndromes) Symptoms (anorexia, early satiety, nausea, dysphagia, change in bowel habit, fatigue, apathy, memory loss, new onset falling) Physical signs (cheilosis and/or angular stomatitis, glossitis, dehydration as below, fluid retention, loss of subcutaneous fat, loss of muscular mass, poor dental status, poorly healing wounds or ulcers or pressure ulceration) Dehydration (increased hemoglobin, increased hematocrit, increased sodium & /or chloride, reduced skin turgor) Laboratory investigations (folate deficiency, iron deficiency, vitamin C at reduced levels, zinc deficiency, serum albumin, transferrin, or pre-albumin reduction, dehydration related laboratory phenomena as above) Adapted from: Geriatric Nutrition Handbook Stephen Bartlett et al 1998 ISBN