348


Part III Standards for Compliance


professionals, as well as the involvement of family members in the resident’s care.


●


Avoid absolute goals, such as a specific caloric intake; present intake goals as ranges instead and document usual intake and body weight, which are easier to defend in court and are real- istically more like the erratic patterns of diet and weight of noninstitutionalized adults.


RDNs must stay up to date on nutritional treatments, such as enteral feedings, wound care, hydration, and current MNT protocols for older adults. Generally, the gold stan- dard of care in the skilled nursing environment is the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87, also referred to as Chapter 483 of the CFR 42)(13). The final regulation or the interpretative guidelines for surveyors published by the Health Care Financing Administration (HCFA)(predecessor to CMS) provide structure and govern facilities participating in the Medicare and Medicaid programs (13). Current MNT protocols, federal and state regulations, practice acts, and the facility’s organizational policies and procedures also are considered standards of care. Acute-care and hospital- affiliated skilled nursing facilities may regard the Joint Commission as another standard.


RDNs are expected to implement appropriate stan- dards of treatment, assessment, and monitoring systems, based on any such standards of care. In addition, the con- tractual agreement may set the standard of care for a con- tracted employee or independent contractor. For example, assume that the contract of an RDN with ABC Facility states that the consultant RDN or licensed dietitian will evaluate all significant weight losses and dialysis resi- dents monthly and that a resident was hemodialized three times a week for an entire calendar year and lost 45 pounds during that period. Assume, as well, that no docu- mentation was done for four of the months during the year by the RDN. The clinical record in this instance con- firms a deviation from the standard of care. If the RDN’s deviation from the standard of care is linked as a caus- ative factor for a negative outcome, then the RDN is pos- sibly at risk for litigation, stress, professional and financial losses, and, in extreme cases, criminal allegations.


FOLLOWING CURRENT INDUSTRY STANDARDS


Box 24.1 shows some current industry standards of care that may help to clarify the role of RDNs in mini- mizing the risk of MNT litigation in the nutrition care and assessment of older adults.


Adherence to all these standards will place the RDN in a relatively strong position. However, if one or


BOX 24.1 ●


Industry Standards of Care


Screen, assess, and evaluate nutritional status, including pertinent anthropometric data, labora- tory data, clinical data, and diet history (14,15). Make appropriate recommendations that follow standards of practice and follow protocols or writing orders if clinical privileges are granted.


● ●


Address hydration status (needs, input and output, laboratory test results, risks).


Make appropriate nutrition recommendations based on current MNT protocols, specifically related to unintended weight loss, enteral feedings, pressure ulcers, hydration, and any other factors that put the resident at nutritional risk.


● ●


Individualize recommendations for each resident.


Record clear, concise statements that identify whether or not the resident is meeting the nutrition, energy, protein, vitamin, mineral, and fluid needs.


●


Document issues in quality assurance (QA) monthly reports or consultant reports. QA reports often are not discoverable (ie, cannot be subpoe- naed for use).


●


Chart in a nonaccusatory manner that does not implicate the facility in any wrongdoing or negligence.


● ●


Address all care plans with nutritionally related information.


Check that care plans match nutrition needs and status as reflected in the assessment, orders, and progress notes.


●


Ensure that the physician’s orders for diet prescrip- tions match the RDN’s documentation and are adequate and appropriate to meet the resident’s needs and wishes.


● ●


Liberalize diets with physician’s consent. Avoid unnecessarily restricted diets.


Make sure recommendations comply with local, state, CMS, and federal regulations and facility process procedures (ie, enteral feedings/dehydra- tion, complete assessments).


●


Do not just sign off on charts. One’s license, finances, and reputation are at risk. Read the chart, visit the resident, and make any changes necessary before signing.


● ● ● ●


Document regularly, per the facility’s policy, on each high risk resident.


Keep a facility tracking list of all high-risk residents and include dates of documentation.


Keep a detailed list of residents documented on each visit.


Document education provided to families and residents in your notes, as well as an explanation of risks/negative outcomes, including time spent with the resident and/or family on controversial topics.


●


Record resident or family refusal/noncompliance. Include waivers or consider education sheets for residents making choices contrary to medical advice.


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