The Issue in Focus

Poor nutritional status is not a normal part of aging and may result in adverse outcomes such as increased risk of developing and delayed healing of pressure injuries, decline in function, dehydration, and increased risk of death (CMS "Revisions to SOM"). Causes of low food and drink intake and impaired nutritional status include depression, inability to eat independently, chewing and swallowing difficulties, medications that inhibit appetite, and cognitive and functional impairments. Organizations that do not take steps to identify the causes of nutritional problems and ensure residents' adequate nutrition and hydration put them at severe risk of adverse outcomes and leave the organization prone to liability and citations for regulatory noncompliance.

Organizations that offer continuing care services (e.g., skilled nursing facilities, assisted living, memory care units) should ensure that the organization takes steps to improve residents' nutritional status. Such organizations can accomplish this by conducting nutritional assessments, by developing individualized care plans that focus on improving nutrition and hydration, by implementing appropriate interventions, and by monitoring interventions for effectiveness.

This guidance article discusses the nutrition and hydration needs of older adults and describes steps aging services organizations can take to improve the nutritional status of residents. Although organizations must take steps to assess residents and implement interventions whenever a resident gains or loses a significant amount of weight, this guidance article focuses mainly on weight loss and impaired nutritional status because such conditions are of particular concern for frail older adults and may result in significant adverse consequences for such individuals.

Nutrition and Hydration Needs of Older Adults

Adequate nutrition and hydration are essential for the body's overall functioning and for the maintenance and repair of cells and organs. Typically, older adults require 30 kcal/kg of body weight, adjusting for weight loss or gain, with a daily protein intake of 0.8 to 1.0 g/kg of body weight per day and no more than 30% of calories coming from fat (DiMaria-Ghalili). Older adults also require foods fortified with calcium and vitamin D to prevent osteoporosis and folic acid and vitamin B to maintain cardiovascular health (National Institute on Aging).

Overall, consuming a diet rich in nutrients may help older adults avoid the onset of certain chronic diseases and conditions. For example, one 2009 study found that older adults who adhered to a Mediterranean-type diet (i.e., a diet characterized by high amounts of fruit, vegetables, legumes, and cereals; moderate amounts of fish and monounsaturated fat; and low amounts of meat, poultry, and saturated fat) and engaged in frequent physical activity had a lower risk of developing Alzheimer disease than individuals who did not adhere to that type of diet or physical activity (Scarmeas et al.).

Protein has also been found to be an important component of an older adult's diet. A 2014 study examining how four different eating plans affected the muscular health of 20 healthy adults ages 52 to 75 found that older adults who consumed more protein than the daily recommended intake increased their rates of muscle protein synthesis and improved their net protein balance, regardless of when the protein was consumed (Kim et al.). Additionally, a literature review examining the findings of seven studies involving 254,489 participants suggests that moderate dietary protein intake may lower the risk of stroke (Zhang et al.).

The amount of fluids an individual needs to maintain adequate hydration varies from person to person and depends on his or her condition (e.g., fluids should be increased if the person has a fever or diarrhea). Typically, older adults require about 30 to 35 mL/kg of body weight of fluids, with a minimum of 1,500 mL per day (Mentes and Kang). Much of an older adult's intake of fluids comes from meals; therefore, factors that affect a person's appetite may also affect his or her fluid intake (CMS "Revisions to SOM").

More information on nutrition for older adults is available from the U.S. Department of Agriculture's Center for Nutrition Policy and Promotion and the Academy of Nutrition and Dietetics. (See Resource List for more information on these and other organizations.) Also see Nutrition Facts for Older Adults.

Nutrition Deficits in Older Adults

Poor nutrition in older adults most often presents as significant weight loss, protein deficits, dehydration, or pressure injuries. Significant weight loss is defined by the Academy of Nutrition and Dietetics and CMS as a loss of 5% of body weight within 30 days, a loss of 7.5% in 90 days, or a loss of 10% in 180 days (CMS "Revisions to SOM"). In addition to weight loss, aging services staff should look for other warning signs that may indicate nutrition or hydration deficits (see Table 1. Warning Signs of Malnutrition and Dehydration). Anorexia, or the sudden loss of appetite or reduction in intake of food, should be identified and treated before weight loss occurs.

Malnutrition, significant weight loss, protein deficits, and dehydration may be caused by a number of physical, psychosocial, and functional factors, some of which are described below (CMS "Revisions to SOM"; Dorner et al.; Vitale et al.; DiMaria-Ghalili).

Mealtime environment issues. Common environmental factors that may negatively impact residents' eating include visual and auditory overstimulation in crowded or loud dining areas, poor lighting, and lack of visual contrast when foods are positioned close together on the plate.

Inability to eat independently. Functional conditions that affect a resident's ability to eat independently include impaired motor coordination of the upper extremities, reduced range of motion, sensory limitations (e.g., blindness), or impaired strength caused by stroke, Parkinson disease, multiple sclerosis, or other neuromuscular disorders.

Cognitive difficulties or dementia. Residents with dementia or cognitive decline may refuse food or drink, be unable to recognize food or drink or understand the approach of the person feeding them, be unable to use utensils owing to motor difficulties, have difficulties chewing or swallowing, or experience unintended weight loss. According to a study of 71 residents in a dementia unit, more than half had significant eating difficulties, and only about one-quarter were able to eat independently (Vitale et al.).

Depression. Older adults with symptoms of depression may refuse food or experience a loss of appetite.

Medications. Certain medications may cause symptoms such as nausea, feelings of fullness, dry mouth, or confusion that affect eating patterns or affect how an older adult's body absorbs nutrients. In addition, the use of diuretics may cause dehydration or loss of appetite.

Gastrointestinal disorders. Disorders such as pancreatitis, gallbladder disease, and liver dysfunction may affect an older adult's ability to digest or absorb nutrients, while constipation may affect appetite. In addition, diarrhea and vomiting can result in dehydration or nutrient loss and can contribute to loss of appetite.

Swallowing problems. Common causes of swallowing difficulties include stroke, pain, lethargy, confusion, dry mouth, diseases of the oropharynx and esophagus, and aspiration pneumonia. A resident's swallowing difficulties may vary from day to day.

Oral hygiene. Residents with poor oral hygiene, ill-fitting dentures, gingivitis, oral pain, or dry mouth may eat or drink less because of difficulties chewing and swallowing or altered taste sensation.

Pressure injuries. Pressure injuries and other skin wounds may also affect residents' nutritional status by increasing demand for energy and protein as required for healing and may lead to weight loss. In addition, poor nutrition and hydration are risk factors for the development and delayed healing of pressure injuries among older adults. According to a 2009 white paper from NPUAP, nutrition-related factors that increase the risk of pressure injuries include compromised nutritional status (e.g., undernutrition, protein energy malnutrition, unintentional weight loss, hydration deficits), low body mass index, reduced food intake, and difficulty eating independently.

Ensuring that older adults consume adequate calories, protein (i.e., 1.25 to 1.50 g/kg of body weight), fluid, vitamins, and minerals helps prevent the breakdown of tissues. (Dorner et al.) In some cases, organizations may want to encourage residents with pressure injuries to eat as many calories and as much protein as they can tolerate to help heal the pressure injuries (CMS "Revisions to SOM"). For more information, see Pressure Ulcers.

Food allergies and dietary restrictions. As the prevalence of food allergies in the United States grows (Food Allergy Research & Education), healthcare organizations must be increasingly aware of the possibility of dietary errors involving residents. A June 2015 report released by the Pennsylvania Patient Safety Authority reveals that of the 285 events involving dietary errors with hospitalized patients reported between January 2009 and June 2014, the most common error reported was meals delivered to patients who were allergic to a food item on the tray (63.5%).

Eight of the 118 events of this nature resulted in serious harm. Other types of events included patients receiving the wrong diet; meals intended for other patients; and meals delivered to patients who were not supposed to receive food by mouth. (Wallace)

Lawsuits Involving Nutrition and Dehydration

Failure to ensure proper nutrition and hydration can leave an organization prone to liability and lawsuits. For example, in a 2009 case, an Ohio jury awarded $6.5 million to the family of a 61-year-old man who died of dehydration and kidney failure 2 days after a 15-day stay at a nursing home for short-term nursing care. Years before, the man had suffered a stroke, which attorneys alleged would cause him to forget to drink when he was thirsty; aides from the nursing home testified that they were unaware of the man's special needs. Although the man experienced diarrhea in the days after his stay, the jury found that the facility failed to provide sufficient liquids. ("$6.5M awarded")

In another case, the family of an 82-year-old woman with Alzheimer disease and diabetes filed a suit against an Illinois nursing home where the patient had been a resident. Staff had discovered bedsores on the woman's heels and sacrum, and although staff subsequently began repositioning her, prosecutors alleged that the staff failed to notify the resident's family about her declining condition in a timely manner. In addition, the suit alleged that the facility failed to provide adequate nutrition to the resident, failed to implement a skin consultation, and failed to keep the wounds clean and dry. The case was settled out of court for $150,000. (Kreisman)

Organizations must also ensure that residents are receiving their nutrition in a manner that is safe. For example, the family of a resident who died after choking on her food in a New Jersey assisted-living facility sued the organization. Two years after the resident moved into the facility, a nurse found the resident choking on food and performed the Heimlich maneuver, dislodging the obstruction. The resident went to the hospital for observation and returned later that day; however, no reassessment was performed at the assisted-living facility, and although the nurse said she completed an incident report, defendants were unable to find it during litigation. Staff informed the resident's physician the next morning, but he did not examine her.

In the days following the incident, the resident was observed to be "leaning to one side and looking tired," but she was not reassessed and her physician was not notified. About two weeks later, the resident again began choking during a meal; when emergency medical services arrived, they discovered that the resident had stopped breathing and that she had "copious amounts of food" in her airway, which they managed to clear. The resident subsequently died in the hospital after being removed from life support. During the trial, the plaintiff submitted evidence that staff inconsistently adhered to organizational policies and procedures addressing response to choking, incident reporting, resident assessment, and physician notification regarding resident change in condition. (Watson v. Sunrise Senior Living Services)

Facilities may also face regulatory sanctions if they fail to provide proper nutrition and hydration. For example, a nursing home in New Haven, Connecticut, was fined in 2012 for improperly administering food through the feeding tubes of two residents. One resident lost 20 pounds over the course of three weeks, and the other was found to be severely dehydrated after staff failed to properly administer liquids over six straight shifts. (Kovner) For more information, see CMS Regulations for Nutrition and Hydration.

Regulations and Standards

CMS Regulations for Nutrition and Hydration

CMS regulates nutrition and hydration in aging services organizations that receive Medicare or Medicaid payments. According to CMS Conditions of Participation, organizations must ensure that residents maintain acceptable levels of nutritional status, receive a therapeutic diet whenever they have a nutrition problem, and receive sufficient fluid to maintain adequate hydration and health.

In order to comply with CMS regulations, organizations should ensure that adequate policies and procedures are in place and that all staff, especially dietary and direct care staff, are educated and trained on the nutrition policies. In addition, organizations should ensure accurate documentation of nutritional assessments and reassessments of residents and interventions implemented to improve nutritional status.

In a 2008 case, a skilled nursing facility received civil monetary penalties because full documentation of fluid intake was lacking for eight residents who were on the facility's focused hydration list. The facility argued to the Department of Health and Human Services (HHS) Departmental Appeals Board (DAB) that it was not required to document fluid intake for all residents and that no specific documentation is required to demonstrate that residents' hydration needs were addressed. The DAB granted that while the facility could have demonstrated compliance through means other than its records (e.g., testimony, laboratory reports), it failed to do so. In addition, according to the facility's own hydration program guidelines, the night shift supervisor is responsible for totaling fluid intake amounts for residents at risk of dehydration. The DAB found that because no such totals were recorded, the facility failed to show how it was determining whether residents were receiving adequate fluids.

The DAB further addressed the lack of fluid intake documentation for one resident who was receiving treatment for an antibiotic-resistant urinary tract infection. The resident's daily flow sheet indicated that she needed at least 1,500 cc (mL) of fluid per day. However, over a period of three days, her daily flow sheets indicated an intake of only 400 cc to 1,000 cc each day. The facility argued that the resident also received a liquid dietary supplement three times daily, but even with the supplements, her documented fluid intake was insufficient. Flow sheets and nurses' notes indicated that the resident was offered fluids at various times, but on only one occasion was it indicated that she drank any of the offered fluids.

However, the DAB found that the facility did not fail to provide adequate fluids to another resident, who had been found to be dehydrated on admission to the hospital with a diagnosis of aspiration pneumonia. The facility argued that according to case law, organizations may be found compliant if a resident becomes dehydrated despite receiving care that is consistent with professional standards. According to the DAB, the resident's dietary progress notes and medication administration record contained ample evidence of assessment of her nutrition and hydration needs and fluid intake, and monitoring of her condition. The DAB reduced the amount of the civil monetary penalty from $100 per day to $50 per day for 13 days but upheld a denial of payment for new admissions for the same period. (Claiborne-Hughes Health Center v. Centers for Medicare & Medicaid Servs.)

CMS Tags Related to Nutrition and Hydration

In November 2016, CMS updated its Guidance to Surveyors for Long Term Care Facilities in the first major rewrite of its Conditions of Participation for long-term care facilities since 1991. The update included several modifications to the requirements for nutrition. Specific tags related to nutrition and hydration include the following:

§483.25 (g). Nutrition. Based on a resident's comprehensive assessment, the facility must ensure the following:

1. The resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless his or her clinical condition demonstrates that this is not possible or resident preferences indicate otherwise.
2. The resident is offered sufficient fluid intake to maintain proper hydration and health.
3. The resident is offered a therapeutic diet when there is a nutritional problem and the healthcare provider orders a therapeutic diet. CMS defines therapeutic diet as "a diet ordered by a health care practitioner as part of the treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet (e.g., sodium or potassium) or to provide mechanically altered food when indicated."
4. A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident.
5. A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

§483.60. Food and nutrition services. The facility must provide each resident with a nourishing, palatable, and well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

§483.60(a). Staffing. The facility must employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. This requirement includes the following:

1. A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian is one who holds a bachelor's or higher degree in nutrition or dietetics granted by an accredited college or university in the United States (or an equivalent foreign degree); has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional; and is licensed or certified as a dietitian or nutrition professional by the state in which the services are performed or, in the absence of state certification, is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization. Dietitians hired or contracted with the organization prior to November 28, 2016, must meet these requirements no later than November 28, 2021, or as required by state law.
2. If a qualified dietitian is not employed full-time, the facility must designate a person to serve as the director of food and nutrition service. This person must meet the following requirements by November 28, 2017 (or by November 28, 2021, for those hired before November 28, 2016):
1. a certified dietary manager, or
2. a certified food service manager, or
3. an individual with similar national certification for food service management and safety from a national certifying body.

In addition, the food and nutrition service director must have an associate's or higher degree in food service management or in hospitality, if the course of study includes food service or restaurant management, from an accredited institution of higher learning; must meet state requirements (if any) for food service managers or dietary managers; and must receive frequent scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

3. The facility must employ sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

§483.60(b). A member of the food and nutrition services staff must participate on the interdisciplinary team.

§483.60(c). Menus and nutritional adequacy. Menus must do the following:

1. Meet the nutritional needs of residents in accordance with established national guidelines
2. Be prepared in advance
3. Be followed
4. Reflect, based on a facility's reasonable efforts, the religious, cultural, and ethnic needs of the resident population, as well as input received from residents and resident groups
5. Be updated periodically
6. Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy      

The update further stipulates that nothing in these requirements should be construed to limit the resident's right to make personal dietary choices.

§483.60(d). Food and drink. Each resident receives and the facility provides the following:

1. Food prepared by methods that conserve nutritive value, flavor, and appearance
2. Food that is palatable, attractive, and at a safe and appetizing temperature
3. Food prepared in a form designed to meet individual needs
4. Food that accommodates resident allergies, intolerances, and preferences
5. Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice
6. Drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration

§483.60(e). Therapeutic diets. Therapeutic diets must be prescribed by the attending physician. The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by state law.

§483.60(f). Frequency of meals. The frequency of meals must be as follows:

1. Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.
2. There must be no more than 14 hours between a substantial evening meal and breakfast the following day—except that when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.
3. Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at nontraditional times or outside of scheduled meal service times, consistent with the resident plan of care.         

§483.60(g). Assistive devices. The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.         

§483.60(h). Paid feeding assistants. For information on this tag, see Ensure Adequate Staffing.          

§483.60(i). Food safety requirements. The facility must do the following:

1. Procure food from sources approved or considered satisfactory by federal, state, or local authorities
2. Store, prepare, distribute, and serve food in accordance with professional standards for food service safety
3. Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption
4. Dispose of garbage and refuse properly

For information on what surveyors are looking for when making an assessment, see the CMS tools Dining Observation and Hydration Status Critical Element Pathway.

CARF-CACC

The Commission on Accreditation of Rehabilitation Facilities–Continuing Care Accreditation Commission (CARF-CACC) requires nutritional assessments to be conducted on residents, and requires the organization to reassess its performance in relation to targets for nutrition (3.D.33.b). Nutrition is viewed as a consideration when determining a resident's person-centered plan, a resident's goals, risk reduction, and wishes regarding end-of-life care (e.g., whether artificial nutrition and hydration would be withheld in accordance with the resident's wishes). In addition, CARF-CACC requires organizations to provide nutritional information about items on their menus, although it does not require a printed menu. (CARF-CACC)

Joint Commission

Joint Commission provision of care PC.02.02.03 for nursing care centers requires organizations to make food and nutrition products available to their residents. It also requires the following (Joint Commission):

• The food and nutrition products must be prepared using proper sanitation, temperature, light, moisture, ventilation, and security. 
• The food and nutrition products must be consistent with each resident's care, treatment, and services.
• The organization must accommodate a resident's special diet and altered diet schedule, unless contraindicated.
• When possible, the organization should accommodate the resident's cultural, religious, or ethnic food and nutrition preferences, unless contraindicated.
• When a resident refuses food, the organization must offer substitutes of equal nutritional value.
• The organization must store food and nutrition products, including those brought in by residents or their families, using proper sanitation, temperature, light, moisture, ventilation, and security.
• Staff must assist residents who require help eating. Special attention should be given to residents with dementia who have either low attentiveness or wander away during a meal. Also, Joint Commission notes that staff can help minimize distraction and confusion during mealtimes by keeping the table setting simple, serving only one or two foods at a time, providing finger foods, and allowing plenty of time to eat.
• The dining areas must be supervised consistent with  residents' needs.
• A food service supervisor should oversee general kitchen management.

Action Plan

Form a Multidisciplinary Team

Action Recommendation: Be aware of CMS regulations related to nutrition and hydration and other applicable regulations and take steps to ensure compliance.

Action Recommendation: Form a multidisciplinary team to assess each resident's nutrition status that includes his or her physician, nurse practitioner, nursing staff, dietitian, speech therapist, and other relevant professionals.

Nutrition improvement strategies in aging services organizations should involve a multidisciplinary team, including individuals such as the resident's physician, nurse practitioner, nursing staff, dietitian, speech therapist, pharmacist, occupational therapist, social worker, a member of the organization's ethics committee, and other staff members as appropriate. Each member of the team can provide a unique perspective. For example, the physician or nurse practitioner can provide information about potential causes of poor nutrition (e.g., anorexia). The speech therapist can address swallowing difficulties, and nursing staff can provide information about nutritional intake. A dietitian can recommend appropriate interventions, and a pharmacist can identify any medications taken by the resident that may affect nutrition by causing nausea or confusion (CMS "Revisions to SOM").

Conduct a Nutritional Assessment

Action Recommendation: Conduct a comprehensive nutritional assessment for each resident upon admission and when a change in condition occurs. Use the assessment to identify any underlying causes of nutrition and hydration problems.

The nutritional assessment is an important step for identifying residents at risk for malnutrition; however, early screening may not always be common practice (Stange et al.). The nutritional assessment involves an evaluation of the person's nutritional needs and goals in the context of his or her overall condition (CMS "Revisions to SOM"). Staff may collect information by interviewing residents and their family members or surrogates and by reviewing records and documents (e.g., medical records) from other sources.

Nutritional assessments should include the following elements (CMS "Revisions to SOM"; DiMaria-Ghalili):

• Current and typical body weight
• Detailed weight history (e.g., periods of intended or unintended weight loss)
• General appearance (e.g., weight; level of consciousness and responsiveness; oral health; condition of hair, nails, and skin)
• Current and typical height
• Medical conditions (e.g., gastrointestinal disorders, chewing or swallowing difficulties) that may affect nutritional status
• Current pressure injuries or history of pressure injuries
• Recent events (e.g., surgery) that may affect nutritional status
• Use of diuretics or medications that may affect nutritional status
• Functional status
• Food and fluid intake         

In some cases, aging services organizations may need to order laboratory tests to identify the causes of poor nutritional status if such information cannot be determined from resident assessments.         

One assessment frequently recommended to determine a person's nutritional status is the Mini Nutritional Assessment, or MNA. This assessment, which determines risk based on food intake, mobility, body mass index, history of weight loss, physiological stress, and the presence of conditions such as dementia, can be used to determine whether the resident has or is at risk for malnutrition. (DiMaria-Ghalili) To assess hydration status, a good resource is the Signs and Symptoms of Dehydration Checklist from the National Resource Center on Nutrition, Physical Activity & Aging.

Develop an Individualized Care Plan

Action Recommendation: Develop an individualized care plan for each resident.

Based on the findings of the nutritional assessment and any other resident assessments, the multidisciplinary team, in collaboration with the resident and family members, should develop an individualized care plan that includes identified causes of nutritional problems, the resident's nutritional preferences, goals for the resident, and planned interventions and time frames for implementing the interventions. The care plan should be updated when the resident experiences a change in condition, when goals are achieved, or when interventions are determined to be ineffective. (CMS "Revisions to SOM")

Implement and Monitor Interventions

Action Recommendation: Implement appropriate interventions and monitor for effectiveness.

Action Recommendation: Respect resident choices and preferences for food and drink when possible.

Action Recommendation: Take steps to ensure that the mealtime environment is pleasant for residents.

In some cases, treating the underlying cause of nutritional deficits (e.g., depression) will improve the resident's nutritional status. For example, if a certain medication is causing nutrition problems, the resident's physician and aging services staff should work with a pharmacist to weigh the benefits of the medication against the risks of impaired nutrition and identify any alternative medications. For residents with swallowing difficulties, a speech pathologist may help with medical management or swallowing therapy for the condition (Vitale et al.). Other examples of interventions that help improve nutritional status are described below.

Dietary interventions. Aging services staff should develop individualized dietary plans with the help of a dietitian to ensure that residents are provided with both appetizing and nutritious food choices. Strategies for increasing food intake include increasing the portion sizes of a person's favorite foods, providing smaller and more frequent meals, providing snacks between meals, providing finger foods that are easy to eat, and adding flavor enhancers to food. Staff may wish to add fats, oils, or proteins to foods for residents with weight or protein deficiencies. (CMS "Revisions to SOM"; DiMaria-Ghalili)

In some cases, restricted diets (e.g., low fat, low salt) may impair a resident's nutritional status because he or she does not like or refuses to eat such foods. According to CMS regulations, when a resident is eating poorly or losing weight, the aging services organization may temporarily decrease dietary restrictions and implement a liberal diet plan in order to increase the resident's food intake and stabilize his or her weight. In addition, the Pioneer Network advocated for liberalized diets in its "New Dining Standards and Practices," recommending that residents start with a general diet, and that dietary restrictions, including therapeutic and texture modification, be ordered only when highly recommended by the physician due to the severity of the resident's condition (Pioneer Network). CMS endorsed the Pioneer Network's recommendations in 2013 (CMS "Information Only").

If necessary, the organization may provide the resident with a dietary supplement to improve nutritional status; however, the organization must first attempt to improve nutrition with food before considering the use of a supplement (Pioneer Network). When offering a dietary supplement, evidence indicates that providing the supplement between meals rather than with meals increases the person's caloric intake (CMS "Revisions to SOM").

Some strategies aging services staff should use to improve hydration include maintaining records of residents' fluid intake, offering small amounts of liquid (e.g., 2 to 4 oz) to residents frequently throughout the day, encouraging residents to drink water or liquid every time they see them, providing residents with sips of liquid in between bites of food, offering ice chips, providing alternative fluid sources (e.g., popsicles, gelatin), providing residents with assistance if they cannot drink independently, adding multiple hydration stations in common areas throughout the building, and ensuring that pitchers and cups can be easily reached and lifted by residents (CMS "Revisions to SOM"; National Resource Center on Nutrition, Physical Activity and Aging).

Resident choice. Residents and their families should be included in decisions on meal options so that the person is more likely to comply with his or her meal plan. The individual's preferences for foods (e.g., ethnic foods) and snacks, meal temperatures, portion sizes, consistency, and eating times should be respected whenever possible.

Organizations should also make efforts to comply with other resident requests during mealtimes. For example, aging services staff should assess and address any of the residents' rituals (e.g., dressing for dinner, washing hands before dinner) or cultural or religious rites (e.g., prayer) for mealtimes (Amella and Aselage).

Environmental interventions. Ensuring that mealtime is a positive experience for residents can also help improve their eating habits and food intake. Aging services staff should help residents anticipate mealtimes by planning food-related activities (e.g., sharing recipes, food-related trivia games) or social gatherings (e.g., celebrating birthdays and holidays) (Vitale et al.). Because evidence indicates that people are more likely to eat when others are present, staff should encourage the resident to eat in the common dining area if possible or should encourage family members to be present during mealtimes (Locher et al.). Other strategies can include offering popular brands of energy or nutrition bars as snacks and placing bowls of fruit in common areas throughout the building to encourage healthy snacking.

Other steps aging services organizations can take to improve the mealtime environment include the following (Amella and Aselage):

• Minimize noise levels and distractions (e.g., television, caregivers' voices) during mealtimes.
• Use standard dinnerware (e.g., china, flatware, tablecloths) as opposed to disposable dinnerware and bibs.
• Seat residents in arm chairs at an appropriate height in relation to the table; avoid feeding residents seated in wheelchairs or in bed.
• Ensure that lighting is sufficient but not glare-producing.
• Play soft, pleasant music preferred by residents.
• Use contrasting background and foreground colors to increase food visibility for residents with impaired vision.
• Prepare food in an area near the dining room to stimulate residents' appetites.         

Artificial nutrition and hydration. The decision to initiate artificial nutrition and hydration for a resident with eating problems is complex and must be made by the individual's physician. In such cases, the physician and other healthcare providers must determine whether the resident has an advance directive that addresses artificial nutrition or hydration or a healthcare proxy responsible for making such decisions.         

If possible, the benefits and risks associated with artificial nutrition and hydration should be discussed with the resident and his or her family early in the course of care before nutritional problems develop (Vitale et al.). Physicians should ensure that residents and families clearly understand the benefits and risks of artificial nutrition and hydration before making a decision about their use.         

For information on whether to initiate artificial nutrition and hydration when the resident is nearing the end of life, see End-of-Life Care.

Monitor Interventions

After interventions are implemented, staff should observe residents to determine their nutritional status, evaluate the effectiveness of nutritional interventions, and identify the development of any new risk factors (e.g., acute illness, pressure injury, fever). The results of staff observations should be adequately documented. The resident's care plan should be revised as necessary depending on his or her progress, response to interventions, and overall prognosis. (CMS "Revisions to SOM")

Resident monitoring should also include recording the resident's weight. Residents should be weighed upon admission or readmission to the aging services facility, weekly for the first four weeks after admission, and at least monthly thereafter, unless the person experiences a change in condition or shows signs of decreased food intake or impaired nutritional status.

Organizations should not use records of a resident's weight from a previous hospitalization or a resident's report of his or her weight in lieu of weighing the resident. Because a person's weight may vary throughout the day, organizations should develop consistent approaches for weight assessment (e.g., weighing the person at the same time of day each time, and in the same type of clothing). In addition, aging services staff should make adjustments to a resident's weight to account for amputations or prostheses if applicable. (CMS "Revisions to SOM")

Weight stability, rather than weight gain, may be the most realistic goal for residents with  nutritional impairments (CMS "Revisions to SOM").

Ensure Adequate Staffing

Action Recommendation: Ensure sufficient staffing to feed residents during mealtimes.

Action Recommendation: Ensure that staff are educated on the organization's policies and procedures related to nutrition and hydration.

Action Recommendation: Consider hiring feeding assistants or training other staff members on appropriate feeding practices or meal assistance.

Organizations must also ensure sufficient staffing to assist residents who need help eating and prevent residents from feeling rushed through meals. When staffing is low, organizations may train staff members not typically responsible for feeding on appropriate feeding practices.

CMS regulations permit aging services organizations to use paid feeding assistants to provide resident meals under certain conditions. According to CMS, paid feeding assistants must be supervised by either a registered nurse or a licensed practical nurse; if such nurses are not available for supervision, the organization is not allowed to use paid feeding assistants. In an emergency, CMS states that the feeding assistant must call a supervisory nurse for help. In addition, feeding assistants may be used only to help residents who have no complicated feeding problems, including (but not limited to) difficulty swallowing, recurrent lung aspirations, and tube or parenteral/intravenous feedings.

The facility must base the decision of whether a paid feeding assistant would be appropriate for a resident on the interdisciplinary team's assessment and on the resident's latest assessment and plan of care; this should be reflected in the comprehensive care plan. Organizations must also ensure that feeding assistants are used in a manner that is consistent with the laws of the state where they are employed and that all feeding assistants complete state-approved training courses.

A 2007 study sponsored by CMS and the Agency for Healthcare Research and Quality found that feeding assistants provided assistance with feeding similar in quality to that provided by certified nursing assistants (CNAs). Almost all feeding assistants employed by the organizations that were studied received at least eight hours of formal training (e.g., written exams, performance-based assessments) on feeding assistance practices, infection control, nutrition, and other relevant information. In addition, no organizations reported that their staffing levels of licensed nurses or nursing aides had changed since they implemented the feeding assistant program, indicating that the organizations were not using feeding assistants to take the place of staff already working in the organizations. (Simmons et al.)

However, observations of feeding practices in the organizations studied indicated that licensed nurses often did not supervise feeding assistants or CNAs providing feeding assistance and that 19% of residents who did not receive feeding assistance ate less than 50% of their meals. The authors noted that aging services organizations should increase licensed nurse supervision during mealtimes, improve identification of residents in need of feeding assistance, and improve the feeding of residents with special needs. (Simmons et al.)

Staff who feed residents should position themselves so they are facing the person whom they are feeding, speak softly to the person or speak louder if the person is hard of hearing, make eye contact, feed the person in small amounts and at a slow pace, verbally prompt the person to chew and swallow, and encourage him or her to eat by positively discussing the food's taste and smell (Vitale et al.).

For more information on approaching staffing challenges faced by aging services organizations, see Responsive Staffing and Scheduling in Aging Services: A Systems REThinking Approach and the video If I Could Change One Thing: Staffing Levels.

Other Risk Management Considerations

Action Recommendation: Ensure that the right diet gets to the right person every time.

Action Recommendation: In cases in which a resident refuses nutrition interventions, encourage him or her to eat or drink, communicate the risks of refusing interventions to the resident and family, and document such efforts.

Action Recommendation: Ensure that staff are educated in the issues surrounding nutrition and hydration as they relate to end-of-life care and are respectful of the decision of the resident and/or his or her surrogates.

Right Diet, Right Person

The Pennsylvania Patient Safety Authority highlights steps organizations can take to ensure that the right diet gets to the right person every time. Although these strategies are designed for hospitals, they can also be applied to aging services organizations. They include the following (Wallace):

• Educate and train staff on food allergies and special diets, and on the proper way to answer resident questions or concerns.
• Create a written procedure for handling food allergies and special diets. The procedure should include who is responsible for identifying the dietary needs of the resident with allergies, how the information will be disseminated to the rest of the staff, when it is appropriate to involve a dietitian, and what the food service staff needs to know to avoid cross-contamination.
• Allow the multidisciplinary team to coordinate the continuum of processes that impact residents with food allergies or other dietary needs.
• Ensure that food services cooks or chefs use only the ingredients listed on a recipe and do not make substitutions.
• Alert the kitchen staff that the resident has an allergy or special diet, and place a ticket on the resident's tray.
• Listen carefully to food service complaints and follow up as appropriate.
• Interface dietary orders with the main hospital's electronic health record so that dietary orders can be automatically updated.         

In addition, it is important for staff to report whenever a dietary error event or near-miss occurs. This can help inform risk managers on the kinds of errors that are occurring, and sharing the information can help stop other staff from committing the same errors.

Resident Refuses Nutrition

Residents have the right to refuse treatment, including nutritional interventions. When a person refuses food or other interventions to improve nutrition, staff should try to encourage him or her to eat and drink and should communicate to the resident and his or her family the risks of refusing interventions. Such efforts should be adequately documented. 

In a 2007 case, the HHS DAB found that a skilled nursing facility did not fail to provide necessary care in allowing a resident who experienced delusions of a religious nature to fast in exercise of his religious beliefs. The 52-year-old resident's diagnoses included blindness in both eyes and schizophrenia, and he generally refused care and food, citing reasons such as his belief that God would heal him or God told him to do so. One morning, the resident was found in bed, looking very weak and short of breath. He was taken to the hospital emergency department where he was given a primary diagnosis of gastrointestinal bleeding and secondary diagnoses including dehydration and cachexia. He died that night.

CMS contended that the resident's fasting should not have been considered a legitimate religious practice because it was "the product of mental illness." It stated that the facility failed to assess and monitor changes in the resident's condition; notify the resident's physician that he was increasingly refusing meals and had lost a significant amount of weight (he lost 10% of his body weight in the month before his death); accurately document his food intake; and have a registered dietitian assess him.

The DAB, however, stated that the resident fasted in accordance with his religious beliefs, agreeing with the facility that he had a right to refuse food. Further, the DAB found that the facility developed and implemented an appropriate care plan: It had the resident assessed by the dietary manager; encouraged him to eat and drink; served him a double-portion, high-protein diet of the specific types of food he requested; and went to "great lengths" to find food he would eat. Additionally, the DAB found that the resident's weight loss did not constitute a significant change in condition for him because his weight often fluctuated greatly as a result of his fasting. (Sheridan Health Care Center v. Centers for Medicare & Medicaid Services)

End-of-Life Care

When residents develop difficulties with eating and drinking during the course of their disease, a decision must be made whether to administer artificial nutrition and hydration. Many medical ethicists and most courts in the United States consider artificial nutrition and hydration administration to be a medical intervention that, like any other medical treatment, a terminally ill resident or his or her surrogate may refuse.

One professional organization that has developed practice guidelines concerning the decision to withhold artificial nutrition and hydration is the American Academy of Neurology. The guidelines state the following:

• The decision to discontinue fluid and nutrition administration should be made in the same manner as other medical treatment decisions.
• Artificial provision of nutrition and hydration is analogous to provision of other forms of life-sustaining treatment, such as respirator therapy.
• Administration of fluids and nutrition by medical means, such as through a gastrostomy tube, is a medical procedure.
• Treatments that provide no benefit to the resident (i.e., medically futile treatment) may be discontinued.
• Artificial provision of nutrition and hydration, like other medical treatments, provides no benefit to individuals in a persistent vegetative state, once the diagnosis has been established.

Other issues that may arise in discussions among residents, families, surrogates, and healthcare providers are whether artificial nutrition and hydration may prolong survival, whether artificial nutrition and hydration may cause the resident to suffer discomfort or burdensome complications, and whether death due to dehydration is painful.

In cases in which artificial nutrition and hydration are withheld, staff should communicate to the individual's family that with palliative care during the dying process, the person does not feel hunger or thirst. Staff should inform the individual's family that the individual will be fed by natural methods until such methods are no longer possible. The family may be encouraged to provide mouth care to the individual with a moist swab or provide small amounts of food if possible. (Vitale et al.)