Change of Condition- Weighty Issues. Janelle L. Asai, RD, LD Asai Consulting, LLC

Transcription

1 Change of Condition- Weighty Issues Janelle L. Asai, RD, LD Asai Consulting, LLC Asai Consulting, LLC 1

2 Materials for today: The OHCA Monthly ALF/RCF Webinar Powerpoint Slides that follow along with what is on your screen. Change of Condition Survey Citations Copy of Oregon Administrative Rules (July 2010 version) Copy Survey Process Guide Appendix C Asai Consulting, LLC 2

3 Phones & Questions Please put your phone on *6 to mute and press * 7 to unmute for questions Type in questions on toolbar. Questions will be answered immediately or held until the appropriate time during the webinar. There will be an open Q & A at the end of the presentation. Bottom line ~ we want to answer your question(s)! Asai Consulting, LLC 3

4 Objectives Learn how to identify significant weight change Review potential risk factors for weight change be prepared Review systems for addressing. Review documentation necessary to demonstrate actions and compliance Asai Consulting, LLC 4

5 Objectives Identify interventions. Quality improvement tools. Asai Consulting, LLC 5

6 RALF -CBC: Short term change of condition Expected to resolve or be reversed with minimal intervention, or Established, predictable, cyclical pattern associated with previously diagnosed condition. Significant change of condition Major deviation from most recent eval that may affect multiple areas of functioning or health Not expected to be short term Imposes significant risk to resident. Asai Consulting, LLC 6

7 Examples of significant change of condition include but are not limited to: Broken bones; Stroke, heart attack, or other acute illness or condition onset; Fast decline in activities of daily living; Significant unplanned weight change; Unmanaged high blood sugar levels; Uncontrolled pain; Pattern of refusing to eat; Level of consciousness change; and Pressure ulcers (stage 2 or greater). Asai Consulting, LLC 7

8 Significant Weight Change Definition A standard in the profession for Older Adults - based on a percentage of weight change over time. 5 % in 30 Days 7.5 % in 90 Days 10 % in 180 Days Asai Consulting, LLC 8

9 Severe Weight Loss Greater than 5 % in 30 Days Greater than 7.5 % in 90 days Greater than 10 % in 180 Days Asai Consulting, LLC 9

10 Why are we concerned? 1. Unintentional weight loss is correlated with: Increased mortality (DEATH ) Compromised ability to resist infections Increased incidence of pressure ulcers Sign of other problems Asai Consulting, LLC 10

11 Why are we concerned? 1. Unintentional weight gain may be related to fluid overload Congestive Heart Failure-Increased mortality (DEATH) Renal Failure- (kidney disease) increased mortality Liver disease (ascites) Asai Consulting, LLC 11

12 Congestive Heart Failure When either chamber (ventricle) is damaged or not working properly, it is unable to pump all the blood it receives. This will cause the fluid in the blood to back up into the lungs. It may also back up further and cause excess fluid in the liver, abdomen, and legs. Asai Consulting, LLC 12

13 Congestive Heart Failure Asai Consulting, LLC 13

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15 Calculating Significant Weight Loss 1. Current weight = 90 pounds Weight 30 days ago = 100 pounds. 2. Current weight divided by weight of 30 days ago 90 divided by 100 = Subtract from = Multiply by x 100 = -10 % Negative number means weight loss Positive number means weight gain Asai Consulting, LLC 15

16 KEY STEPS in IDENTIFICATION 1. Weight policy?- get out your policy to review 2. Who takes them? 3. When are they taken 4. What are they wearing? 5. What about that scale? Asai Consulting, LLC 16

17 KEY STEPS in IDENTIFICATION 1. Who records them -where? 2. Who reviews them? And when 3. What about reweighs? 4. Consider parameters for reweighs 5. Weekly weights- if you are not going to review them weekly- why take them? Asai Consulting, LLC 17

18 SYSTEMS FOR MONITORING Asai Consulting, LLC 18

19 Weight Record Room # Resident Dec Jan Feb March April May June July August Sept Nov Dec Asai Consulting, LLC 19

20 WEIGHT ANALYSIS RECORD September 09 RESIDENT CURRENT WT 30 day Var % change 90 day Var % change 180 Var % change Interventions Hillary Clinton % % % supplements Bill Clinton % % % Simon (2) -1.23% 161 (1) -0.62% 161 (1) -0.62% % % % Brad Pitt % % % Angelina Jole % % % Jen Aniston (5) -4.10% % % qowk Asai Consulting, LLC 20

21 St. Andrews Care Center- Darcy Hood APT NAME PY Jul PY Aug PY Sep PY Oct PY Nov PY Dec Jan Feb 101 Justin Timberlake Day Verification 0.00% -2.67% 90 Day Verification -1.32% -3.95% 180 Day Verification 5.63% -4.58% 102B Jim Carlson Day Verification 0.00% -1.11% 90 Day Verification 1.69% -3.78% 180 Day Verification 9.76% -2.73% 109b Janelle Asai Day Verification -4.76% -8.33% 90 Day Verification -1.64% -9.09% 180 Day Verification -4.76% % 117B Martha Stewart Day Verification -3.29% -4.76% 90 Day Verification % -9.09% 180 Day Verification #DIV/0! #DIV/0! 213 Linda Kirshbaum Day Verification -4.42% -5.56% 90 Day Verification -9.24% % 180 Day Verification -6.90% % 412A Yoko Ono oof Day Verification 5.05% -1.92% 90 Day Verification -6.31% 0.00% 180 Day Verification % % 413 Barack Obama Day Verification % 10.37% 90 Day Verification % % 419 Michelle Obama Day Verification -3.23% -2.50% 90 Day Verification -6.25% -5.65% 180 Day Verification -7.69% % Asai Consulting, LLC 21

22 QUESTIONS? Asai Consulting, LLC 22

23 Significant Weight Change Identified? Response-what are your policies? 1. Evaluate the resident 2. Refer to appropriate medical care 3. Refer to community RN 4. Evaluate and update service plan 5. Arrange for follow up care/? MD visit 6. Include RN in Service Plan update or LN sign off in 48 Hours (phone call to RN if not on site) 7. Document all evaluations, interventions, monitoring, promptly Asai Consulting, LLC 23

24 Review by RN to include Were all weights accurate? Is the weight loss due to a decrease in edema new diuretic order? Is the resident on any medication that could cause true weight loss? What can the resident tell you about her appetite, and wt loss? Consulting Resources- Darcy Ryan, RN, MS Asai Consulting, LLC 24

25 RN review What are the resident s food preferences and does she like the food here? How is her appetite? Any dental or dysphagia problem? Is the resident depressed? Is pain playing a role? What are resident s wishes regarding weight? Consider referral to RD Possible service plan interventions Asai Consulting, LLC 25

26 Documentation RN-assess any resident with a significant change of condition Full, focused, chart review, phone consult Role in ongoing monitoring defined in policy LN participate on Service Plan team or review and sign Service Plan in 48 hours Asai Consulting, LLC 26

27 Monitoring and Reporting What is your policy for monitoring? Asai Consulting, LLC 27

28 Systems for communication Changes in service plan promptly to key players Information communicated to staff? How is it the word spread? Communication to staff- shift to shift Instructions in place i.e., on service plan or alert charting system Asai Consulting, LLC 28

29 ACTION STEP- What can you do to be prepared? Asai Consulting, LLC 29

30 Pre- move in- Risk factors evaluated -assessed? Diseases: Cancer, renal disease, diabetes, depression, Chronic Obstructive Pulmonary Disease (COPD), Parkinson s, Alzheimer s, dementias. Tremors? CHF and CKD -weight gain Other Failure to thrive, History of weight change, Malnutrition, infection, dehydration, constipation, diarrhea, pressure ulcers, dysphagia, anorexia Asai Consulting, LLC 30

31 Pre-move in risk evaluation-can you meet current special diet needs and future ones? Review you disclosure statements What diets do you say you can provide? Do you know what they are? Entire team understands diets community can provide? Asai Consulting, LLC 31

32 Modified Special Diet Definitions In Oregon Assisted Living Facilities and Residential Care Facilities this refers to : "Modified Special Diets" meaning a diet ordered by a physician or other licensed health care professional that may be required to treat a medical condition (e.g., heart disease or diabetes); Asai Consulting, LLC 32

33 Modified Diets in Oregon Small frequent meals, no added salt, reduced or no added sugar and simple textural modifications Medically complex diets are not included. Examples of medically complex..? Asai Consulting, LLC 33

34 Medically Complex RENAL DIET-75 gram protein, 2 gram sodium, 2 gram potassium, 1000 milligrams phosphorus. Fluid restriction mls. Gluten Free-this is almost impossible in our setting. Puree diet with honey thickened liquidsdysphagia. Strokes, dementia, parkinsons Asai Consulting, LLC 34

35 Risk factors evaluated -assessed? Bedfast, totally dependent for eating Use of assistive devices, cueing & supervision Asai Consulting, LLC 35

36 Risk factors evaluated -assessed? Food cultural and/or religious preferences, Allergies & special diets Ethnic food needs Vegan Milk Protein allergy Asai Consulting, LLC 36

37 Risk factors evaluated -assessed? Use of medications such as diuretics, laxatives, or cardiovascular agents Asai Consulting, LLC 37

38 Risk factors evaluated -assessed? Chewing/swallowing problems, no teeth, ill fitting dentures, mouth pain, taste/sensory changes Asai Consulting, LLC 38

39 INTERVENTIONS Action Steps Asai Consulting, LLC 39

40 Resident Interview What are the resident s wishes and preferences? Asai Consulting, LLC 40

41 Food First 1. Fortified foods program 2. Larger portions of favored meals or items 3. Snacks between meals Asai Consulting, LLC 41

42 Dining Program Concerns? How does the food taste and look?? meals served were palatable and nutritious and met the needs of the resident.? resident voiced concerns regarding the taste, temperature, quality, quantity and appearance of the meal served Asai Consulting, LLC 42

43 Weight Loss interventions 2. Food preference review? 3. Modified diet liberalization? Asai Consulting, LLC 43

44 FOOD SUBSTITUTIONS? ( Resident Services- Meal substitutions must be of similar nutritional value if a resident refuses a food that is served.) Two entrees? Choices? Always available list of foods? Grilled cheese sandwich, cottage cheese and fruit, chicken breast, hard cooked eggs?? Asai Consulting, LLC 44

45 Weight Loss interventions 1. Texture changes or finger foods 2. Dentition issues-modified texture needs- mechanical soft- Is it dry and bland Asai Consulting, LLC 45

46 Dining Program Concerns? Mechanically altered diets, such as pureed, prepared and served as separate entree items (except for combined foods, e.g., stews, casseroles, etc.); Asai Consulting, LLC 46

47 What does the puree diet look like? Asai Consulting, LLC 47

48 Mechanical soft textures Asai Consulting, LLC 48

49 DYSPHAGIA? 1. Coughing before, during, or after swallowing 2. Need to swallow 3-4 times with each bolus 3. Frequent throat clearing 4. Hoarse, breathy, or wet voice; gargling while breathing 5. Sensation of something caught or stuck in the throat 6. Drooling Asai Consulting, LLC 49

50 DYSPHAGIA? 1. Spillage of food or liquid from the mouth 2. Frequent sneezing during eating 3. Pocketing food in the cheeks 4. Oral-buccal akathisia (protruding tongue movements) 5. Repeated pneumonia 6. Increase body temperature 7. Chest/lung congestion Asai Consulting, LLC 50

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52 Thickened Liquids-use commercially pre-thickened Nectar Honey Pudding Foods? No ice cream Soup Gelatins x Asai Consulting, LLC 52

53 Weight Loss interventions 1. Adaptive equipment Asai Consulting, LLC 53

54 Weight Loss interventions 1. Depression? Remeron- increases? Pyscho-actives may decrease 2. Medication change Asai Consulting, LLC 54

55 Weight Loss interventions 1. Environmental o Lighting, crowded, unpleasant- all 5 senses addressed Enhance lighting and avoid glare Aging brings changes in visual acuity and performance. An older retina, taking in less light, requires more light than that of a younger person Asai Consulting, LLC 55

56 Weight Loss interventions Change in eating assistance- not identified? Eating Strategies 1. One item at a time-distractibility 2. Decreased stimulation at meal times 3. Portable for food residents on the go Timing Issues- 1. Late risers-? snack program is enhanced 2. Nocturnal what about night time snacks. Asai Consulting, LLC 56

57 Weight Loss interventions Gastrointestinal issues- constipation or diarrhea. Food intolerances- lactose Pain Asai Consulting, LLC 57

58 Nutrition Supplements Avoid at meal times Consider with medication pass System for documentation- if its not documented it wasn t given Chart mls taken or have policy to address Consider products with at least 1.5 calories per ml of product. Anything less- you might as well give whole milk. Asai Consulting, LLC 58

59 Review- Service Plan Do you do more than paper compliance? Asai Consulting, LLC 59

60 Service Plans? Develop using the clinical conditions and risk factors identified in the evaluation Evaluate your Service plan and revise based on the response, outcomes, and needs of resident Asai Consulting, LLC 60

61 Service Plan-consistent implementation Are you doing what you say you are doing? Asai Consulting, LLC 61

62 Delivery of care in Service Plan? Staff providing assistance and/or encouragement during dining; Serving food as planned with attention to portion sizes, preferences Nutritional supplements Between-meal snacks Asai Consulting, LLC 62

63 QUESTIONS Asai Consulting, LLC 63

64 Highlights of Investigative Protocol Protocol is to be used when a sampled resident has an unplanned weight change Risk factors and Dining assistance needs evaluated Asai Consulting, LLC 64

65 Highlights of Investigative Protocol 1. Review of service plan Developed utilizing clinical conditions/ risk factors identified? Appropriate and followed, revised as needed? 2. Observation of the delivery of care as described in the service plan Asai Consulting, LLC 65

66 Highlights of Investigative Protocol 1. Meal observation-at least two meals observed during the survey. 2. Food service observation - Delivery to residents in a timely fashion; substitute arrive timely; and diet orders, portion sizes, preferences, and condiment requests being honored. Asai Consulting, LLC 66

67 Highlights of Investigative Protocol 1. Interviews of the resident, family and/or significant other 2. Sample Tray may be requested 3. Determination of how much of the meal the sampled resident consumed. Asai Consulting, LLC 67

68 Determination of Compliance: Determining factor in compliance for change of condition and monitoring related to unplanned weight change, is the proper evaluation and assessment, development and implementation of the service plan, evaluation/assessment of the resident outcome, and revision of the service plan as needed if it is not effective. Asai Consulting, LLC 68

69 Quality improvement tools BE PREPARED Asai Consulting, LLC 69

70 Asai Consulting, LLC 70

71 WEIGHT ANALYSIS APT NAME PY Jul PY Aug PY Sep PY Oct PY Nov PY Dec Jan Feb 101 Justin Timberlake Day Verification 0.00% -2.67% 90 Day Verification -1.32% -3.95% 180 Day Verification 5.63% -4.58% 102 Jim Carlson Day Verification -0.97% -3.41% 90 Day Verification -0.49% -2.94% 180 Day Verification 3.02% -2.46% 103 Linda Kirshbaum Day Verification -4.76% -8.33% 90 Day Verification -1.64% -9.09% 180 Day Verification -4.76% % 104 Martha Stewart Day Verification 1.27% -2.50% 90 Day Verification 5.26% 0.00% 180 Day Verification 6.67% 1.30% 105 Rosalie Vogel Day Verification -3.29% -4.76% 90 Day Verification % -9.09% 180 Day Verification #DIV/0! #DIV/0! 106 Janelle L. Asai Day Verification 6.29% 5.92% 90 Day Verification 3.40% 15.00% 180 Day Verification #DIV/0! #DIV/0! 107 George Baily Day Verification -4.42% -5.56% 90 Day Verification -9.24% % 180 Day Verification -6.90% % Asai Consulting, LLC 71

72 CASE STUDY Joelle Smith is a 90 year old woman who moved into the Happy Land Senior Community on Her diagnoses included: Alzheimer s Dementia, Rheumatoid Arthritis, and Vitamin B 12 deficiency. Asai Consulting, LLC 72

73 Weight on move in: # Diet: General Regular Food Preference: None reported. Appetite- reported excellent prior to move in. Liked to eat small amounts throughout the day. Medication list: Aricept, methotrexate, folic acid, Celebrex, prilosec, and Multivitamin with minerals, Vitamin B 12 once a month, Vitamin D Units per day. Her family was no longer able to care for her in her home because she was exit seeking and her dementia progression had increased her care needs. No behavior issues noted. Due to her R.A., required finger foods for self feeding. Asai Consulting, LLC 73

74 Provide general regular diet. Snacks between meals prn. Weights # : 123 # : 120 # Weekly weights ordered: : 130 # : 121 # Supplements ordered Next weight : 115 # Meal observation: Resident did not receive finger foods. She refused her supplements, but no one told anyone about that. The kitchen just kept sending them out. Snacks provided were pudding and crackers at 2 PM. Asai Consulting, LLC 74

75 What should have happened for this resident? Care issues Documentation Service Plan Asai Consulting, LLC 75

76 Answers Significant weight loss 2 times Was the weight policy followed Service plan not followed- finger foods Snacks not finger foods Lack of documentation-supplement Lack of follow through on system of communication Training Asai Consulting, LLC 76