Institutional Policies/Procedures Excerpts (Example for this case)

During your orientation you reviewed the policies and procedures that have been put in place by the previous consultant dietitian.
They include the following:

Procedure

–   Implementation of the following locally developed forms at the specified frequencies (Click on name of form to see an example)

–   Dietitian Inititial Assessment — Completed as part of the admission screening by the dietitian as required by MDS RAI Manual 3.0 - Completed by Day 14

–   Food Preference Form— to be completed upon admission and when updates are needed, by either the Certified Dietary Manager or a Dietitian

–   Dietary Intake Form  — to be completed as part of a Dietitian's Initial Assessment, usually completed by a dietitian

–  Dietary Intake Records - to be completed for three meals per month unless the dietitian requests more often

–  Restorative Dining Tracking  Intake Reports — The CDM or the CNA involved in Restorative Dining provide intake reports to the dietitian.  In this facility the CDM puts the report in the dietitian's inbox.  The Restorative Dining records are part of the electronic health record and dietitian needs to access them from the EHR. 

-  Interdisciplinary Care Plans  -- The Baseline Care Plan is inserted by the admissions team.  The dietitian completes the dietary section within 24 hours (NOTE:  In this case Bertha was admitted yesterday, so you are completing this section today -- within 5 days of admission). 

The CMS does NOT require a separate Nutrition Care Plan IF there is no nutritional problem.  However facilities also have their own requirements. 

Your facility DOES REQUIRE a nutrition care plan regardless of whether there is a nutritional problem or not and it needs to be placed in the record within 14 days of admission.  

Your facility has a template to be used for interdisciplinary nutrition care plans.  The dietitian is responsible for initiating care plans to address nutritional issues and/or having a working nutrition care plan in the record for "No Nutrition Diagnosis at this time" if appropriate.  The care plan identifies actions to be taken by the dietitian, Certified Dietary Manager or Dietetic Technician, Registered, as well as other members of the interdiciplinary health care team (CNA for dining assistance, RN for Weights, SLP for evaluation for swallowing difficulties, etc).  

–  Dietitians Re-assessment — Completed as part of the comprehensive assessment required at quarterly, annual, and significant change as per MDS RAS Manual 3.0

–   Monthly Monitoring and Evaluation/Re-Assessment Risk Tracking Form — to be completed a minimum of once per month to document the key findings from the dietitians' review of nutritional status and care needs)

–   Dietitian Coordination Note Form— Completed whenever there is a change in nutrition intervention that needs to be communicated with the CDM or other healthcare team members.  If more than one healthcare team member needs to be informed of the change, then the form is duplicated.  If there are separate issues that need to be communicated to different healthcare team members, then one coordination form for each healthcare team member is completed.

–   Dietitian Recommendation Form — Completed whenever there is a change that needs to be made that requires a physician order, e.g.. frequency of taking weights, diet order, laboratory tests or referrals to other healthcare team members (Social work, Occupational Therapy, Speech Language Therapy).  This form may be used less frequently once the dietitian has requested, been evaluated, and been granted order writing privileges by the institution. 

NOTE:  Anytime there is a newly hired dietitian they will  NOT have order writing privileges at this time.  In the future after being employed for at least 6 months consultant dietitians can then apply for order writing privileges.  The previous dietitian who had been there for 30 years had privileges to write orders for:

• Orders for weights (can order monthly, weekly, or daily weights)
• Orders for changes in diet, such as changes in texture modifications, adding or changing in between meal supplements, and laboratory tests (e.g.. BMP or lipids)

–   Care Planning Meeting — The Certified Dietary Manager attends all Care Planning Meetings.  The dietitian attends as needed in person or by telephone if the care planning meetings occur on days that the dietitian is not in the facility.  The dietitian determines whether there has been significant change in the resident's health status that would require her input to the care planning process.  For example the dietitian would usually attend if there was a significant weight change, nutrition diagnoses of malnutrition or unintended weight loss.  

–   Therapeutic Diet Ordering -- In this facility there is a joint document signed by the Medical Director, Nursing Director, Food Service Director, and Consultant Dietitian that describes the diet ordering clarification.  Excerpts from this document follow:

When modified diets are ordered without specific calories or grams, the following will be prepared and served. Nursing is to clarify the diet order with the attending physician. We are trying to liberalize the diets to improve diet compliance and acceptance by the residents. The consistency of foods and/or fluids are to be included in the written diet orders and approved by the physician. The Academy Nutrition Care Manual is our official reference for diets (www.nutritioncaremanual.org)

One of the specialized diets common in residential care/skilled nursing facilities are diets for dysphagia.  A recent initiative has standardized the terminology used (2019), The International Dysphagia Diet Standardization Initiative (IDDSI) identifies the 8 levels (0 to 7) to describe food textures and drink thickness.  Drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7.  

The IDDSI framework is a diagram summarizes the levels and words and descriptions of these levels.  

Diet orders may need to specify both the food texture and fluid consistency when necessary, for example, a Level 4 diet would combine both food and beverages, e.g. Level 4 would be "Pureed food with Extremely thick" fluids or Level 3 would be "Liquidized food and Moderately thick" fluids.  

The Centers for Medicare and Medicaid Services (CMS) is encouraging the use of liberalized diets for Long Term Care residents. We will honor resident wishes in this regard. Each resident has the right to consume their desired foods/beverages. Therefore, we will honor “diet liberty per resident’s rights” for all residents.

–   Ordering texture modified diets:

There are two parts to diet orders related to texture modification:  the therapeutic component (from the House Diets in the table above) and the texture modification for both food and liquid as shown below:

For example a diet order would be NAS/ Mechanical Soft (Level 6)/ Liquids (Level 0)