Multi-disciplinary Meal Audits: How to ensure

the best meal service for residents

Susan Goldberg, MEd, RD and Halina Jaros, NM

Our Plan today:

• Introduction to Copernicus Lodge • Key MOH legislation and regulations • Dining Inspection protocols • The multi-disciplinary audit • Other Inspection protocols • Case Study • Conclusion

History of Copernicus Lodge:

• 1979 – first opened seniors apartments • 1983 – 3 floors for LTC – 108 beds • 1995 – Supportive Services for apt. seniors • 2004 – new LTC Home built on property • Big change for Dietary staff and PSWs in 2004! • 1983 – residents came to the food – 1 DR • 2004 – food goes to the residents – 10 DRs

Set up for the Polish community

Current Overview

• Not for profit long term care home • 210 seniors in our apartments • 226 long term care beds + 2 short stay • ~ 20 people in Adult Day Program, 4 days/wk • We also sell meals for staff, free for volunteers • = 900 meals per day, mostly home cooked,

fresh soup twice per day

Copernicus Lodge – 228 beds LTC facility 10 RHA’s Each has a dining room On 4 floors, 1 servery serves 2 dining areas On 2 floors, just one servery/dining room http://www.copernicuslodge.com/longtermcare.html

Key MOH and LTC regulations regarding meal service:

1. must have a process in

place 2. congregate setting 3. choices 4. meal times 5. meals and snacks 6. preserve taste, nutrition,

appearance, and food quality

7. feeding assistance/positioning

Inspection Protocols

A “Dining Observation Inspection Protocol” is conducted when inspectors are in the home Inspectors will look to see if home is providing

a positive dining experience (pleasurable dining) Will interview resident’s/SDM’s to assess food

palatability, temperature, satisfaction

Inspection Protocols

Thus, we ask questions of residents, families How does food taste, too hot, too cold? How are you enjoying your meals? These records help us evaluate resident

satisfaction, and are used to continuing quality improvement (CQI) purposes, as well as annual reporting purposes

Inspection Protocols • Inspectors also want

to know that residents are assisted and monitored at meals, wherever they eat

• They want to be sure all residents are receiving the planned menu

Inspection Protocols

Thus, we ask questions of staff – Both dietary staff and PSW staff – Want to be sure they understand the process in

place to be sure individual needs are being met – Also, want to be sure they understand the

importance of monitoring, and how to articulate the monitoring they are doing

Therefore, the meal audit tool was developed to: • Ensure compliance with key MOH regulations

regarding meal service • Determine if there are gaps in resident/SDM

satisfaction with meals • Verify staff understanding of the meal processes • Confirm that staff are assisting and monitoring

residents at meals

What questions are asked during the audit process?

Audit of - Dining Service

? Refer to diet book – all PSW and dietary staff were trained on how to use the book

? Therapeutic extensions – dietary staff trained ? Menus posted ? If eating in room, needs to be in care plan ? Take their time ? Serve course by course ? Seating plans

Audit of - Menu Planning

? All offered a choice ? Juices poured when residents are seated ? Labelled snacks given between meals, not

with meals

Audit of - Food production

? Temperature logs kept ? Foods covered on trays ? Foods refrigerated as

appropriate ? Pureed foods served

separately

Audit of - Residents dependent on staff for feeding

? Do staff feed no more than 2 people at a time ? Table rotation schedule followed ? Are meals plated just prior to being served ? Are staff feeding sitting at the same level of the

person being fed ? Feed those on pureed diets by tsp ? Check tables, environment for safety and

attractiveness; for example wobbly tables

Audit of - Positioning and Assistance

? Assistive devices and feeding aids ? If using a feeding aid, is this in care plan ? Verbal encouragement ? Place cups/utensils in hands ? Eye contact, socialization ? Correct positioning

Other Inspection Protocols

• Nutrition and Hydration • Dignity, Choice and Privacy

Nutrition and Hydration

• IP specifies that an RD must be involved in the development of the nutrition and hydration program, and its policies and procedures.

• In our home, it is policy to provide everyone with water and milk at all meals

• Thus, we audit to ensure adherence to this policy

Nutrition and Hydration

• Care intervention strategies would be looked at, to determine if they are effective

• These strategies are in the care plan • Thus, we randomly choose 1 resident and look

at their care plan, and ensure that the care specified in the care plan is what we are providing (and visa versa)

Resident’s Rights and Dignity

• Residents are to be given Choice, Control, Respect

• Includes dietary needs and preferences • Includes honouring individual needs of residents • Thus, we audit:

1. Bibs 2. Washclothes 3. TV off and music playing 4. Staff awareness of policies regarding residents who

request something that is not on the diet list

Case Study

• Mr. E.M. • 92 yrs old • Med hx: dementia, CHF, HTN • Eats breakfast in bed, lunch

and supper in unit dining room • Needs extensive assistance

with feeding by staff • Top denture only • Able to hold a cup by himself

Case Study

• daughter had taken a copy of the menu, and highlighted in pink highlighter which foods staff were to give resident.

• Experienced significant wt loss and low albumin

• LBM’s • Lengthy talk with daughter. Turns out he

really likes cake and cookies. • She agreed to eliminate the highlighted

menu, and let him receive items like everyone else

Case Study • Had been in hospital and assessed by

SLP who recommended pureed diet • Daughter suggested he required

pureed foods only because of meds affecting his swallow ability at that time; once these meds are D/C’ed, she asked if he could possibly now swallow soft foods

• Assessment done by RD; he could chew and swallow soft textured foods with no difficulty noted (ham slices, potato salad, beans)

Case Study

• Diet was changed to: Low lactose diet, soft texture with pureed soup, with 1 scoop protein powder od, 1 muffin and 125mls juice (am), 125mls applesauce (pm), 1 serving cake (hs).

• Resident began to gain weight • Albumin improved and protein powder D/C’ed

In Conclusion Meal time is central to nutritional care, and therefore overall

health care, for residents in LTC The Interdisciplinary team is involved in ensuring this

resident’s optimal nutrition: SLP, RD, PSW, dietary aide, family, MD, RN, resident themselves

Staff needed to monitor resident’s ability to feed self, level of assistance required, food intake, food tolerances

Socialization with other residents and caregivers positively impacts food intake

Nutritional care must be individualized Making choices at meals, and implementing snacks according

to food preferences, is essential to good nutrition

In Conclusion

By focusing on proper processes at meal time, positive outcomes could be achieved:

•Optimal nutritional status

•Quality of life

In Conclusion

Registered

Dietitians and Dietary Managers play a leadership role in improving health, nutrition and quality of life

for residents in LTC.

References • Meal times as active processes in Long-term Care Facilities;

Gibbs-Ward, A.J., Keller, H; Can J of Diet Prac and Res; 66(1); 2005

• Position of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health care Communities; J of Am Diet Assoc; 110(10); 2010

• The Relationship between difficulties feeding oneself and loss of weight in nursing-home patients with dementia; Berkhout et al; Age and Aging; 27; 1998

• Nutritional Management in Long-tem Care: Development of a Clinical Guideline; Thomas et al; J of Geront 55A(12); 2000.