Change of ConditionWeighty Issues Janelle L. Asai, RD, LD Asai Consulting, LLC
[email protected]
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The OHCA Monthly ALF/RCF Webinar Materials for today: 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
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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)!
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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
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Objectives
Identify interventions. Quality improvement tools.
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RALF -CBC: 411-054-0040
Short term change of condition Expected to resolve or be reversed with minimal intervention, or Established, predictable, cyclical pattern associated with previously diagnosed condition.
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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. 6
Examples of significant change of condition include but are not limited to:
Broken bones; Stroke, heart attack, or other acute illness or condition onset; Unmanaged high blood sugar levels; Uncontrolled pain;
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Fast decline in activities of daily living; Significant unplanned weight change; Pattern of refusing to eat; Level of consciousness change; and Pressure ulcers (stage 2 or greater).
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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
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Severe Weight Loss
Greater than 5 % in 30 Days Greater than 7.5 % in 90 days Greater than 10 % in 180 Days
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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
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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
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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.
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Congestive Heart Failure
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Calculating Significant Weight Loss 1.
2.
3. 1.
Current weight = 90 pounds Weight 30 days ago = 100 pounds. Current weight divided by weight of 30 days ago 90 divided by 100 = .90 Subtract from 1. .90- 1= - .10 Multiply by 100. -.10 x 100 = -10 % Negative number means weight loss Positive number means weight gain Asai Consulting, LLC
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KEY STEPS in IDENTIFICATION 1.
2. 3. 4.
5.
Weight policy ?- get out your policy to review Who takes them? When are they taken What are they wearing? What about that scale ?
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KEY STEPS in IDENTIFICATION 1. 2.
3. 4. 5.
Who records them -where? Who reviews them? And when What about reweighs? Consider parameters for reweighs Weekly weights- if you are not going to review them weekly- why take them? Asai Consulting, LLC
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SYSTEMS FOR MONITORING
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Weight Record Room #
Resident
Dec
Jan
Feb
March
April
May
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July
August
Sept
Nov
Dec
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WEIGHT ANALYSIS RECORD September 09
Var
% change
139
4
2.88%
2.59%
190
8
4.21%
(1)
-0.62%
161
(1)
-0.62%
146
4
2.74%
142
8
5.63%
13.33%
165
5
3.03%
169
1
.59%
2
1.82%
111
1
0.90%
109
3
2.75%
(5)
-4.10%
115
2
1.74%
107
10
9.35%
RESIDENT
CURRENT WT
30 day
Var
% change
90 day
Var
% change
180
Hillary Clinton
143
140
3
2.14%
138
5
3.62%
Bill Clinton
198
198
0
0.00%
193
5
Simon
160
162
(2)
-1.23%
161
150
145
5
3.45%
Brad Pitt
170
150
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Angelina Jole
112
110
Jen Aniston
117
122
Interventions
supplements
qowk
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St. Andrews Care Center- Darcy Hood APT 101
NAME PY Jul PY Aug PY Sep PY Oct PY Nov PY Dec Jan Feb Justin Timberlake 142 153 150 152 152 150 150 146 30 Day Verification 0.00% -2.67% 90 Day Verification -1.32% -3.95% 180 Day Verification 5.63% -4.58% 102B Jim Carlson 164 183 179 177 185 180 180 178 30 Day Verification 0.00% -1.11% 90 Day Verification 1.69% -3.78% 180 Day Verification 9.76% -2.73% 109b Janelle Asai 126 127 124 122 121 126 120.00 110.00 30 Day Verification -4.76% -8.33% 90 Day Verification -1.64% -9.09% 180 Day Verification -4.76% -13.39% 117B Martha Stewart 0 0 0 165 154 152 147 140 30 Day Verification -3.29% -4.76% ……………………………………………………………………………………………………………………………………………………………………………… 90 Day Verification -10.91% -9.09% 180 Day Verification #DIV/0! #DIV/0! 213 Linda Kirshbaum 116 118 118 119 115 113 108 102 30 Day Verification -4.42% -5.56% 90 Day Verification -9.24% -11.30% 180 Day Verification -6.90% -13.56% 412A Yoko Ono 117 117 oof 111 102 99 104 102 30 Day Verification 5.05% -1.92% 90 Day Verification -6.31% 0.00% 180 Day Verification -11.11% -12.82% 413 Barack Obama 0 0 0 195 215 190 164 181 30 Day Verification -13.68% 10.37% 90 Day Verification -15.90% -15.81% 419 Michelle Obama 130 130 127 128 124 124 120 117 30 Day Verification -3.23% -2.50% 90 Day Verification -6.25% -5.65% 180 Day Verification -7.69% -10.00%
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QUESTIONS?
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Significant Weight Change Identified? Response-what are your policies? 1. 2. 3.
4. 5. 6.
7.
Evaluate the resident Refer to appropriate medical care Refer to community RN Evaluate and update service plan Arrange for follow up care/? MD visit Include RN in Service Plan update or LN sign off in 48 Hours (phone call to RN if not on site) Document all evaluations, interventions, monitoring, promptly Asai Consulting, LLC
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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
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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
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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
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Monitoring and Reporting
What is your policy for monitoring?
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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
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ACTION STEP- What can you do to be prepared?
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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
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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
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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
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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……..?
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Medically Complex
RENAL DIET-75 gram protein, 2 gram sodium, 2 gram potassium, 1000 milligrams phosphorus. Fluid restriction- 1500 mls. Gluten Free-this is almost impossible in our setting. Puree diet with honey thickened liquidsdysphagia. Strokes, dementia, parkinsons Asai Consulting, LLC
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Risk factors evaluated -assessed?
Bedfast, totally dependent for eating Use of assistive devices, cueing & supervision
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Risk factors evaluated -assessed?
Food cultural and/or religious preferences, Allergies & special diets
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Ethnic food needs Vegan Milk Protein allergy
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Risk factors evaluated -assessed?
Use of medications such as diuretics, laxatives, or cardiovascular agents
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Risk factors evaluated -assessed?
Chewing/swallowing problems, no teeth, ill fitting dentures, mouth pain, taste/sensory changes
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INTERVENTIONS Action Steps
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Resident Interview
What are the resident’s wishes and preferences?
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Food First 1. 2.
3.
Fortified foods program Larger portions of favored meals or items Snacks between meals
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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
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Weight Loss interventions 2. 3.
Food preference review? Modified diet liberalization?
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FOOD SUBSTITUTIONS?
(411-054-0030 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
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Weight Loss interventions 1. 2.
Texture changes or finger foods Dentition issues-modified texture needs- mechanical soft- Is it dry and bland
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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.);
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What does the puree diet look like?
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Mechanical soft textures
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DYSPHAGIA? 1. 2. 3. 4.
5.
6.
Coughing before, during, or after swallowing Need to swallow 3-4 times with each bolus Frequent throat clearing Hoarse, breathy, or wet voice; gargling while breathing Sensation of something caught or stuck in the throat Drooling Asai Consulting, LLC
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DYSPHAGIA? 1. 2. 3.
4.
5. 6. 7.
Spillage of food or liquid from the mouth Frequent sneezing during eating Pocketing food in the cheeks Oral-buccal akathisia (protruding tongue movements) Repeated pneumonia Increase body temperature Chest/lung congestion Asai Consulting, LLC
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Thickened Liquids-use commercially pre-thickened
Nectar Honey Pudding
Foods? No ice cream Soup Gelatins
x Asai Consulting, LLC
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Weight Loss interventions 1.
Adaptive equipment
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Weight Loss interventions 1.
Depression
? Remeron- increases ? Pyscho-actives may decrease
2. Medication change
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Weight Loss interventions
Environmental Lighting, crowded, unpleasant- all 5 senses addressed
o
Enhance lighting and avoid glare
1.
Aging brings changes in visual acuity and performance. An older retina, taking in less light, requires more light than that of a younger person
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Weight Loss interventions 1. 2. 3.
1. 2.
Change in eating assistance- not identified? Eating Strategies One item at a time-distractibility Decreased stimulation at meal times Portable for food residents on the go Timing IssuesLate risers- ? snack program is enhanced Nocturnal –what about night time snacks. Asai Consulting, LLC
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Weight Loss interventions
Gastrointestinal issues- constipation or diarrhea. Food intolerances- lactose Pain
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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
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Review- Service Plan Do you do more than paper compliance?
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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
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Service Plan-consistent implementation
Are you doing what you say you are doing?
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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
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QUESTIONS
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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
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Highlights of Investigative Protocol 1.
Review of service plan
2.
Developed utilizing clinical conditions/ risk factors identified? Appropriate and followed, revised as needed ?
Observation of the delivery of care as described in the service plan
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Highlights of Investigative Protocol 1.
2.
Meal observation-At least two meals observed during the survey. 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
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Highlights of Investigative Protocol 1.
2. 3.
Interviews of the resident, family and/or significant other Sample Tray may be requested Determination of how much of the meal the sampled resident consumed.
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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
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Quality improvement tools BE PREPARED
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WEIGHT ANALYSIS APT 101
NAME PY Jul PY Aug PY Sep PY Oct PY Nov PY Dec Jan Feb Justin Timberlake 142 153 150 152 152 150 150 146 30 Day Verification 0.00% -2.67% 90 Day Verification -1.32% -3.95% 180 Day Verification 5.63% -4.58% 102 Jim Carlson 199 203 206 206 204 207 205 198 30 Day Verification -0.97% -3.41% 90 Day Verification -0.49% -2.94% 180 Day Verification 3.02% -2.46% 103 Linda Kirshbaum 126 127 124 122 121 126 120.00 110.00 30 Day Verification -4.76% -8.33% 90 Day Verification -1.64% -9.09% 180 Day Verification -4.76% -13.39% 104 Martha Stewart 150 154 150 152 156 158 160 156 30 Day Verification 1.27% -2.50% 90 Day Verification 5.26% 0.00% 180 Day Verification 6.67% 1.30% 105 Rosalie Vogel 0 0 0 165 154 152 147 140 30 Day Verification -3.29% -4.76% …………………………………………………………………………………………………………………………………………………………………… 90 Day Verification -10.91% -9.09% 180 Day Verification #DIV/0! #DIV/0! 106 Janelle L. Asai 0 0 151 147 140 143 152 161 30 Day Verification 6.29% 5.92% 90 Day Verification 3.40% 15.00% 180 Day Verification #DIV/0! #DIV/0! 107 George Baily 116 118 118 119 115 113 108 102 30 Day Verification -4.42% -5.56% 90 Day Verification -9.24% -11.30% 180 Day Verification -6.90% -13.56%
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CASE STUDY
Joelle Smith is a 90 year old woman who moved into the Happy Land Senior Community on 12-10-10 Her diagnoses included: Alzheimer’s Dementia, Rheumatoid Arthritis, and Vitamin B 12 deficiency.
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Weight on move in: # 130 Diet: General Regular
12-07-10 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 D3 1000 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
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Provide general regular diet. Snacks between meals prn. Weights 1-10-11 122 # 2-15-11: 123 # 3-07-11: 120 # Weekly weights ordered: 3-14-11: 130 # 3-21-11: 121 # Supplements ordered Next weight 3-28- 1: 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
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What should have happened for this resident? Care issues Documentation Service Plan
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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
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