When the Right Documentation Tools Helps Empower Residents in Long-Term Care

2018 marks the 31st year of the 1987 Nursing Home Reform Law. Emphasizing individual dignity and self-determination, this law requires nursing homes meet these requirements if they participate in Medicare or Medicaid.

To honor all residents living in long-term care facilities, The Consumer Voice named October “Residents’ Rights Month”. It is an opportunity to focus on and celebrate the dignity, respect and rights of each resident in long-term care. We thought we’d take a cue from this year’s theme – “Speak Up: Know Your Rights and How to Use them” – and discuss residents’ rights from the nutrition and diet perspective in this three-part blog series. In part 2, we discuss how documentation can help you reduce complaints that can factor into your 5-star rating.

Many times, people have their hearts in the right place, but don’t have the tools to successfully make the change to person-centered dining practices. In this blog, Diane Hall, President of BSN Solutions, talks with her Regional Director, Gail Douglas, using a real-life incident that stresses the importance of documentation to reduce complaints that may factor into the 5-Star rating.

DIANE: So, Gail, this is a story about a resident who was hesitant to attend a birthday celebration because of an incident that previously happened to her. Share with us what happened, and we’ll talk about some of the tools you used to help prevent this unpleasant situation.
GAIL: Sure.  So not long ago, a woman in our care — we will call her Evelyn — was new to the community.  It just so happened that our monthly birthday celebrations were coming up.  Since it was Evelyn’s birthday that month, our activities director made sure to invite her to the event.  But Evelyn told me she didn’t want to go because of something that happened to her at another community where she used to live.

DIANE: What was that?
GAIL: Evelyn was excited to meet everyone and went to the birthday event with a happy heart. The room was very festive with streamers and balloons put up. Since her birthday was one of the ones being celebrated, she was given a party hat to wear and made the master of the ceremonial cake cutting. Well, after she sliced the cake, so everyone could enjoy a piece, the activities director handed her a bowl of fruit instead of a slice of cake.

DIANE: I assume that she wanted a piece of cake like everyone else?
GAIL: She sure did and when she didn’t get one, it embarrassed her in front of her new neighbors. Then when she asked for some cake, she was told that she wasn’t allowed to have any because she was on a “No Concentrated Sweets” diet because of her diagnosis of diabetes. In fact, the activities director insisted that she had to follow an NCS diet, according to the updated diet list that she referenced at the party. Anyway, Evelyn left the gathering feeling rejected and ashamed. It made her so sad that she had to live under the rules imposed by the staff members of the community and wasn’t able to fully enjoy her birthday celebration.

DIANE: So, that’s why she was gun-shy about attending the birthday party in your community?
GAIL: Right. So, to make her comfortable, the two of us discussed her diet regarding her diabetes and what she wanted to do. She told me she usually ate a healthy diet at home with lots of fruits and vegetables, and occasionally indulged in a cookie. As a dietitian, I keep up with the latest evidence-based research and, according to clinical guidelines of the American Medical Directors Association, a no-concentrated sweets diet is no longer appropriate for treatment of diabetes in long-term care communities since there is no evidence to support its effectiveness. So based on the current information, I knew that older people living in long term care communities can include some simple sugars (such as cake and cookies) as part of an overall healthy diet. Anyway, after we talked a little more, I assured Evelyn that her request to follow a Regular diet without restriction by staff, would be addressed.

DIANE: It’s surprising to me that so many communities like the one Evelyn came from were still sticking to the old guideline and prescribing diabetic diets (NCS) to older adults. I mean, look at the evidence from The New LTC Dining Standard, plus the position paper Liberalization of the Diet Prescription Improves Quality of Life for Older Adults In Long-Term Care from the Academy of Nutrition and Dietetics, and the Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. All this information supports the practice of liberalizing NCS restrictive diets towards a regular diet.
GAIL: Had the care partners in that other community taken the time to just ask Evelyn how she usually managed her diet at home, and then provided her with the information about the risks and benefits of her diet choices, they could’ve avoided a whole bunch of mistakes. Embarrassing someone in front of his or her new neighbors is not ok. Not “allowing” a slice a birthday cake is not ok. Not using the most current evidence-based research is not okay. But then again, maybe they didn’t have the documentation tools they needed to honor and manage Evelyn’s choice.

Four documents communities need to support person-centered dining practices

  1. Declaration of Dining Independence. The Declaration of Dining Independence reveals that residents value the right for control and choice, but it also explains we understand and accept the responsibility of the consequences from our decisions. A great handout to create a groundswell of support for self-directed dining.
  2. Current Evidence-Based Research Regarding the Risks and Benefits of Dietary Restrictions in Long-Term Care. These forms are used to discuss the risks and benefits of dietary restrictions with the resident, giving them consistent, up-to-date information so they can make an informed choice about their meal plan and document that the person understands the risks if they choose to refuse dietary restrictions.
  3. Care Plan Documentation.  A document used to guide the discussion on liberalizing diets and records the residents’ wants and goals when it comes to what, when and where they want to eat. Asking such questions as: Are you having any current problems with your diet? Why is changing your diet important to you? Does anything about changing your diet concern you? Documenting the resident’s response as a direct quote leaves no doubt about what a person wants since it is there in black and white. There is also a section that discusses the individualized approaches developed by the care team to make the resident’s choices as safe as possible, managing equally quality of life and quality of care.  Based on the care planning process created by the Rothschild task force and our own experience, this documentation form is designed to help meet the requirements of the final rule from CMS regarding person directed care.
  4. Dining Surveys and Assessments of Dining Requirements. These documents support QAPI practices by Identifying any issues with the residents’ dining experience and are designed to catch any potential issues that could lead to complaints and or citations leading to Performance Improvement Projects to close the gaps in performance.

Focus on person-centered care

DIANE: Looking at this incident from a marketing standpoint, imagine what Evelyn must have told her friends and family about the staff member at the first community who denied her a slice of birthday cake and made her feel small in front of her new neighbors as opposed to what Evelyn told her about you listening to her about what she wanted and then focusing on making that happen.
GAIL: Right. I think focusing on person-centered care is a smart way to help you improve your rating when it comes to comparing your nursing home to another. And it is a requirement now, so we all need to get with it.  That other community could have avoided the whole embarrassing mess had their team had the proper documentation in place to record what Evelyn wanted when it came to her diet, and to discuss the individualized approaches to make those choices as safe as possible.

Let’s talk more about your long-term community needs.

About Gail Douglas

Gail joined BSN Solutions as a Regional Director in March of 2013. Her role is to promote the adoption of the new dining standards and person-centered dining throughout the communities serviced by BSN Solutions. She also recruits, coordinates placement of, and supports the dietitian consultants who work with BSN Solutions in its client communities. Gail has a vast 30+ year background in long-term care, having worked within skilled nursing and rehab centers in clinical and management capacities. She holds a Master’s degree in Healthcare Administration as well as a Bachelor of Science degree in Human Nutrition.
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