The following posts are all about how our elderly could enjoy eating. There are five posts to this subject-about making the dining experience better; about assisting residents to eat; actual state survey results on DIETARY regulations that were tagged during an inspection…

Survey Date: 9/15/2004

Regulation Number:0369, level D scope/severity

Regulation Title: DIETARY SERVICES

Regulation Description: The facility must provide special eating equipment and utensils for residents who need them.

Surveyor Findings:

Based on observation, record review and staff interviews, the facility failed to ensure two (#5, #13) out of 16 sample residents received the necessary adaptive equipment and utensils during their meals. Specifically, the facility failed to provide resident #5 with plastic utensils during all meals. This failure increased the risk of injury to this resident as described as a safety issue in the medical chart. The facility failed to provide a built up spoon, scoop bowl and ensure proper alignment of the plate guard for resident #13. This failure increased the risk of resident decline with self feeding. The findings included:

1. Non-interviewable sample resident #5 was admitted to the facility on 12/23/00 with the diagnoses of organic brain syndrome, cystic fibrosis, osteoarthritis, diabetes mellitus 2, and depressive disorder. The Minimum Data Set (MDS) reflected the resident’s cognitive skills for daily decision-making as severely impaired. Also, the MDS reflected the resident had periods of restlessness, fidgeting, and repetitive physical movements. The mental function varied throughout the course of the day with behaviors. The behavioral symptoms included physical abuse, resists care and wanders.

Sample resident #5 was observed in the dining room from 9/13/04 through 9/15/04:
–On 9/13/04 at 12:30 p.m., the resident was observed eating her meal with a regular silverware fork. The staff provided occasional verbal and physical cues to assist the resident with handling the fork during food intake.
–On 9/14/04 at 8:21 a.m., the resident was given her silverware (fork, knife and spoon) to use during breakfast by the staff.
–On 9/14/04 at 12:25 p.m., the resident was served her meal. The staff unfolded the napkin surrounding the regular utensils and placed the silverware by the residents’ plate of food.
–On 9/15/04 at 8:38 a.m., the resident was observed eating her breakfast meal. The regular silverware was positioned beside the meal plate.

A diet slip accompanied the plate of food for sample resident #5:
–On 9/14/04 at 8:23 a.m., the diet card revealed, “Plastic silverware with meals.”

The care plan, dietary notes and medication administration record (MAR) were reviewed on 9/14/04:
–The care plan dated 8/10/02 stated, “has a safety issue with regular silverware.” The care plan approach stated to have plastic silverware with meals.
–The dietary progress note dated 7/2/04 stated, “Resident uses plastic silverware for safety reasons.”
–The MAR for June, July and August of 2004 reflected, “plastic silverware for resident and resident at same table daily.”

On 9/15/04 at 1:00 p.m., the Rehabilitation Director and Administrator were interviewed about the use of regular silverware for resident #5, instead of plastic silverware as ordered on the MAR and diet slip:
“I don’t know why she’s supposed to have that.” “I think the plastic might break.” “The plastic fork is sharper.”

Surveyor Findings:

2. Non-interviewable sample resident #13 was admitted to the facility on 8/19/97 and had diagnoses that included Huntington’s chorea. Review of the computerized physician’s orders indicated the resident was to receive a plate guard for increased independence in eating.

Review of the care plan dated 8/18/04 indicated, “Chop meats, long noodles etc to make easier to eat. Set up meals. Adaptive silverware. Needs a large adaptive tablespoon for eating. Uses plate guard.” The care plan indicated the resident had some difficulty with feeding himself.

The resident was observed on 9/14/04 at 8:45 a.m., seated in a wheelchair in the dining room. The resident was served his meal. The CNA positioned the metal plate guard to the right of the plate. The resident had scrambled eggs at nine o’clock on his plate. The resident had regular silverware. The resident was using the spoon and using his right hand to eat. The resident was scooping the eggs to the left, off of the plate, onto the table and floor. With every bite the resident attempted to take the eggs fell onto the table or onto the floor.

The resident was observed on 9/15/04 at 8:45 a.m., seated in a wheelchair in the dining room. The resident was served his meal. The CNA positioned the metal plate guard at the top of the plate. The resident was served a built-up, curved fork and regular knife and spoon. The resident had a regular bowl with fruit loops. The resident’s eggs were along the left side of the plate. The resident’s hash browns were at four o’clock. The resident’s cut up sausage was at the top of the plate. At 8:49 a.m., the resident’s metal plate guard snapped off the plate and was resting on top of the resident’s food. The resident picked up the plate guard and put it on the table. At 8:51 a.m., the resident used his spoon and tried to scoop up a piece of egg towards the left. The egg fell onto table. The resident tried to use his left hand to push the piece of egg onto the spoon but the egg then fell onto the floor. With every bite the resident attempted to take, the food fell onto the table or onto the floor.

On 9/15/04 at 8:58 a.m., the resident started to eat his fruit loops out of the regular bowl. Every time the resident placed the regular spoon into the bowl, he would scoop the fruit loops up and towards the left. Half of the resident’s fruit loops fell onto the table.

During an interview with the rehab manager on 9/15/04 at 10:45 a.m., she stated the facility had plenty of adaptive equipment in house. The rehab manager stated the resident probably popped of the metal plate guard because of his ataxia. The rehab manager stated they could give the resident a scoop plate and bowl.

Survey Date: 5/5/2004

Regulation Number:0369, level D scope/severity

Regulation Title: DIETARY SERVICES

Regulation Description: The facility must provide special eating equipment and utensils for residents who need them.

Surveyor Findings:

Based on observation, record review, staff and resident interviews, the facility failed to provide special eating equipment for one (#4) of 24 sample residents. Specifically, the facility failed to provide resident #4 with ordered and care planned built-up utensils and lip plate or plate guard. This failure created the potential for frustration and this resident’s activities of daily living (ADLs) to decline, rendering the resident dependent for feeding, rather than independent. The findings were:

Interviewable resident #4 was admitted to the facility 04/30/01 with diagnoses that included Parkinson’s, depressive disorder, essential hypertension, vitamin B-complex deficiency, and constipation. The resident’s Minimum Data Set (MDS) ratings dated 04/18/04 and 01/29/04 for eating were 2 and 2, indicating limited assistance necessary and one-person physical assist necessary.

Observation in the assisted dining room on 05/04/04 at 8:30 a.m. showed a CNA placing a plate of breakfast food on the table in front of the resident. Observation showed the plate was not lipped, but a standard plate without a plate guard.

At 8:42 a.m. and 8:43 a.m., the resident was observed taking small bites of pureed eggs and pureed biscuits and gravy with a regular spoon. There was no built-up silverware on the table for the resident to use. The resident was scooping the food, using the regular spoon in his right hand, knuckles up.

At 12:18 p.m., the resident was observed using a regular fork with his right hand. The resident was scooping food off a regular plate that did not have a plate guard or a lipped edge.

Observation in the assisted dining room on 05/05/04 at 8:15 a.m. showed the resident was served a plate of breakfast foods. The plate did not have a plate guard or lipped edge. At 8:16 a.m., the director of nursing (DON) entered the assisted dining room and stated, “You have no silverware (built-up).” At 8:19 a.m., the DON stated, “and you have the wrong plate.” The DON explained how a lipped plate would make it easier to scoop his food, and the resident agreed. The DON was observed rising to exchange the regular plate for a lipped one and stated, “let me get you different silverware, too.”

Observations at 8:23 a.m. showed the resident attempting to use the weighted, built-up spoon. The DON stated the weighted spoon was too heavy, and left the assisted dining room to find an occupational therapy representative (OTR).

At 8:30 a.m., the DON returned with the OTR, who suggested a foam utensil rather than a weighted one. At 8:32 a.m., observation showed the OTR had returned to the assisted dining room with a washcloth and spoon. The OTR was observed wrapping the washcloth around the regular spoon and taping it tight.

At 8:39 a.m., the resident was observed trying to use the washcloth-covered, built-up spoon. He was largely unsuccessful; the spoon was put in his hand as one would hold a pen. Observations had shown the resident preferred to hold utensils in a closed fist with his knuckles facing upward. This position allowed the resident to maximize the utensil surface by keeping it flat as he scooped the food.

At 8:41 a.m., observation showed the OTR placing her hand on the outside of the resident’s hand on the washcloth-covered, built-up spoon to guide the resident in loading food and moving it to his mouth.

At 8:48 a.m., observations showed the OTR feeding the resident with no assistance from the resident. The OTR and DON discussed trying a rocker spoon at lunch. The OTR stated, “He’s done trying for now.”

Record review of a plan of treatment for outpatient rehabilitation dated 02/05/04 stated “use built-up utensils and plate guard.” Nutritional assessments dated 04/07/03, 06/30/03, 10/03/03, 12/13/03, 02/01/04, and 04/30/04 listed lip plate under the adaptive devices category.

Record review of the dietary card indicated “lip plate/weighted utensils.” The dietary card was updated after an interview on 05/04/04 with the DON and nursing home administrator (NHA).

Record review of an interdisciplinary progress note dated 02/04/04 at 12:00 p.m. indicated, “Patient screened by skilled OT (occupational therapist) for feeding. Patient having increased difficulty feeding self per CNAs.” An interdisciplinary note dated 02/05/04 stated, “OT eval completed. Recommend 5-6 visits x 2 weeks to address feeding.” An interdisciplinary note dated 02/16/04 at 5:30 p.m. stated, “Self feeding setup SBA with weighted spoon/plate guard . . . patient liked weighted spoon.”

Record review of a dietary progress note dated 12/13/03 stated, “Continues to feed self independently and lip plate provided.”

Record review of a care plan with a target date of 05/03/04 indicated lip plate as an approach to maintaining weight. A care plan dated 02/20/04 indicated a problem of decreased ability to feed self with standard plate and utensils. The OT goal listed was that the patient would feed self using built-up utensils and a plate guard. The approach listed was “patient to be provided with built-up utensils and plate guard at every meal, to eat in assisted dining room.”

During an interview on 05/04/04 at 3:30 p.m. with the DON and NHA, it was indicated the dietary department was responsible for setting out adaptive devices, such as built-up utensils, as ordered. The dietary department was also responsible for providing plate guards or lipped plates, as appropriate.

During an interview with the resident on 05/05/04 at 3:37 p.m., the resident stated, “that plate guard is okay. That special plate (lipped plate) is pretty neat - your food doesn’t fall off your plate.”

Facility Plan of Correction:

1. Resident #4 was provided built-up silverware and a lipped plate on 5/4/04 and the dietary card was updated to include “lip plate/weighted utensils”. 2. A facility audit will be completed to identify residents who have recommendations for adaptive equipment. Dietary cards will be audited to ensure adaptive equipment is listed on the residents’ dietary cards. 3. An in-service for nursing staff was conducted on 5/19/04 and 5/20/04 on adaptive equipment and providing special eating equipment and utensils for residents who have been assessed to need them. Dietary staff will be in- serviced the week of 6/1/04 on how to identify different types of adaptive equipment and the responsibility of setting out this equipment for identified residents. 4. Dietary Manager, Dietitian and/or designee will monitor weekly and as needed for compliance. The results of the above audits/reviews, and related action plans will be reported to and reviewed by the Performance Improvement Committee x90 days and quarterly thereafter.

Preparing For A Meal

It is imperative that we care for our residents as we would for ourselves or for our own loved ones. Before eating, we normally do several things to prepare for mealtime. Prior to the meal, each resident should be comfortable and clean. This includes toileting, washing hands and face, and good oral hygiene. It also includes being sure the resident has dentures in, glasses on and hearing aides in, as appropriate.

When assisting a resident to the dining room, take care to position the resident at a sitting angle as close to a 90 degree angle as possible. Table heights should be appropriate for the resident to comfortably reach the food.
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Adjustable table tops may be needed to assurewheel chair arms fit underneath the table and that residents who are small can reach easily. Dining rooms should not be overcrowded—residents should be able to move in and out freely, even in wheelchairs.

Pleasant conversation is common courtesy and will promote the resident’s feeling of importance, dignity and self esteem. After positioning the resident, inform them about when the meal will be served, and what is on the menu for that day.

If a resident is eating in his or her room, clear the bedside table of unnecessary items, position the resident at as close to a 90 degree angle as possible (in a chair or in bed as appropriate for the resident) and inform them when they can expect their meal.

Always be sure to wash your hands before and after working with each resident. This is essential to good infection control.

When serving a meal to a resident, always use positive comments to describe the food. The goal is to get residents to eat, and to provide a pleasant dining atmosphere that encourages dignity, enhanced self esteem and socialization. “This is chicken casserole, and boy does it smell good” is sure a lot more positive than “Oh, looks
like mystery meat again!” It is especially important to positively identify pureed foods for residents. The pureed diet is usually the same food as the regular diet; however, if you aren’t sure what the food is, be sure to ask.

Before serving, check the foods on the tray against the tray card to be sure the resident receives the correct tray and the correct diet. Place the tray within the resident’s reach, and ask if they need assistance with opening packages, buttering bread, cutting food, pouring or mixing beverages. Be sure to ask the resident if he or she needs help—do not just automatically assume they need help. Always ask if they want condiments, salt or pepper on their food. Assist them with their napkin or clothing protector if needed. Help them to arrange food so that it within reach, and easy to handle.

Encourage residents to do as much for themselves as possible. Encourage them to eat the meal first, then the dessert and/or supplement last. Notify the nursing supervisor of residents who may benefit from special feeding devices such as plate guards, skid guards, built up utensils, rocker knives, special spoons, sippy cups, etc.

Residents Who Need Assistance With Eating

Promote independence in eating by encouraging residents to do whatever they can for themselves. Encourage them to hold and eat finger foods, hold and use a napkin, and participate in feeding any way they can. Independence with eating may have an impact on their feelings of self worth and good health. Special feeding devices may be very helpful in promoting independence.

When residents must be fed, there are general guidelines which should be followed. Always wash your hands before and after feeding a resident to control the spread of infections. Take time to converse with the resident and socialize with the resident. Make them feel comfortable with the process. Self feeding is frequently the last activity of daily living that a resident can do independently, and it is very difficult when they become dependent on others for such a basic human need. Empathize with the resident, and feed them the way that you would want to be fed. Remember that feeding should only be done by staff that has been trained in feeding techniques.

Feeding Skills and Special Adaptation

Problem/Challenge Possible Adaptation
· One handedness; difficulty cutting meat
· Poor hand coordination
· Hand deformity, difficulty grasping
· Limited neck motion— unable to tilt
head back
· Muscle weakness
· Visual Problems
· Shakiness
· Rocker knife or roller knife
· Weighted utensils, scoop dish,
cups with slotted opening
· Built-up handles on eating utensils
· Cut-out Plastic cup (nose cup)
· Utensil holder, two handled
· Clock method for locating food
scoop dish. For field of vision
within resident’s field of vision
· Sippy cup, swivel utensils.

2003 Becky Dorner & Associates
Becky Dorner, RD, LD is a speaker and author who provides publications, presentations, and consulting
services to enhance the quality of care for our nation’s older adults. Visit www.BeckyDorner.com for free
articles, newsletters, and information.

“I Haven’t Had a Thing to Eat All Day…”
Nutrition for the Dementia Resident
by Becky Dorner, RD, LD

Anna was a delightful lady that everyone quickly fell in love with, myself included. She would spend her days
wandering around the facility, visiting everyone, charming them with warm smiles and conversation, and her joy
of life. Because she was walking constantly, Anna was always hungry. She’d come to me and say, “I haven’t
had a thing to eat all day” even though I knew she always ate well. Somehow Anna knew I would provide her
with compassion, care, and best of all, with food.

Residents with dementia frequently have nutritional problems which can lead to unintentional weight loss and
malnutrition. Here are a few tips to assure proper nutrition and hydration for residents with dementia.
Implement Proper Systems

1. Assure adequate staffing at mealtime to assist residents to the dining area, serve the food, and
verbally/physically cue or assist those who need help.

Trained and dedicated staff alert to warning signs are the key to success in preventing malnutrition and dehydration. Warning signs include: leave >25% of food uneaten, difficulty chewing/swallowing, refuse substitutions; hide food instead of eating it; and/or wander away before they finish the meal.

2. Adequately assess needs for proper diet and cater to individual preferences as much as possible.
Nutrition screening and thorough assessment are needed. Set up automatic referral to the dietetics
professional for high risk residents.

3. Have good preventive systems in place for nutritional care to prevent problems such as weight loss,
malnutrition, pressure ulcers, infection and poor wound healing. Early identification of problems allows
effective interventions for each individual.

Creative Solutions for Specific Problems

Dining Distractions and dining atmosphere can have a major impact on how well a resident with dementia
eats. Keep distractions to a minimum: A low noise level with calming classical music, soft colors and few
interruptions. Appropriate and strategic seating: Family style seating may be good for one resident, but
another may benefit from being in a smaller dining area with fewer people, or even one-on-one dining with staff.

Individualize seating to meet each resident’s needs. Provide a regular routine: Present meals at the same
time and in the same place each day, with a variety of favorite foods presented nicely. Allow adequate time to
eat.

“Sundowner Syndrome” occurs when a resident is more disoriented and distracted after the sun goes down.
This may interfere with food intake at dinnertime and bedtime snack. The Alzheimer’s Association makes these
suggestions for residents with Sundowner Syndrome:
• Decrease caffeine (coffee, tea, chocolate, colas, etc.) or restrict to early morning hours to decrease
agitation and sleeplessness.
• Offer an early dinner or a late afternoon snack to encourage better food intake.
Eating assistance is frequently needed for those who lose the ability to use utensils for eating, become
distracted and have difficulty focusing on eating.
• Promote independence. Encourage independence with eating through use of adaptive feeding devices,
finger foods, verbal or physical cueing, hand-over-hand assistance, and proper positioning for eating.
• Promote dignity and self-esteem. Residents may stop eating halfway through the meal or may
rearrange food on the plate without actually eating it. Supervise, monitor and redirect as needed,
providing gentle reminders to eat.

Weight Loss and Malnutrition: Studies indicate that residents with Alzheimer’s disease are more likely to lose
weight compared to control groups. This may be due in part to increased energy requirements as a result of
increased activity (walking, pacing or agitation). Couple this with forgetting to eat, forgetting how to eat or being
distracted from eating, and this is a dangerous combination for health.

• Offer foods that are high in calories and protein, so that every bite packs a punch. Enhanced foods
are often better accepted than high calorie/high protein supplements alone.
• Have healthy snacks available at all times. Offer snacks when a resident is willing to eat. (But try not to
ruin their appetite for the regular meal).
• Be very attentive at mealtime. Encourage eating, redirect, remind or assist as needed, and address any
mealtime concerns.
• Keep diets as liberal as possible while still maintaining good health. Overly restrictive diets reduce the
palatability of foods and contribute to poor food intake. A therapeutic diet is not effective if it is not
consumed.
• Fortified foods and supplements may be needed, but try other interventions first (assistance at
mealtime, address cognitive and behavioral issues including possible depression, provide favorite foods,
etc.). High calorie/protein, nutrient dense foods such as fortified cereal, potatoes, soups and sauces can
boost calories and protein in the foods already being served.

Dehydration is a concern due to altered thirst sensation, fear of incontinence, inability to request adequate
fluids and medication side effects. Encourage at least six to eight 8-ounce glasses of fluid each day.
• Offer fluids multiple times throughout the day (upon every contact).
• Offer a variety of fluids, being sure to offer favorite beverages. Or try popsicles, sherbet, jello, fruit
slushes, or other forms of fluid.

Caring Intervention
Residents with dementia depend on us for their care and well-being. Adequate assistance, preventative
screening, and intervention for nutritional problems will help to assure the nutritional health of these residents
and prevent further health complications later. So the next time a resident tells you, ”I haven’t had a thing to eat
all day” you’ll know how to intervene with compassion, care, and best of all with food.

2003 Becky Dorner & Associates
Becky Dorner, RD, LD is a speaker and author who provides publications, presentations, and consulting
services to enhance the quality of care for our nation’s older adults. Visit www.BeckyDorner.com for free
articles, newsletters, and information.

Quality food and food service are integral to quality of life for older adults in nursing homes. There is little known about residents’ perspectives on this issue. It is known that when the relationship between appetizing food, quality food service, and quality of life in nursing homes is investigated, residents indicate that they often dislike the food served to them and find it unappetizing because of appearance, lack of variety, or failure to address their personal preferences. The present study examined residents’ perspective about quality dining in nursing homes and described the implications for practice.

A phenomenological approach was used to discover meaning in a series of ‘tell me a story’ resident interviews. Tape-recorded interviews were completed with 20 nursing home residents who told stories about their food and food service and described a perfect mealtime. The pattern, “Fostering a Quality Dining Experience” contained five themes derived from residents perspectives; Choosing Food, Getting Good People, Getting Good Service, Choosing Surroundings, and Getting Enough to Eat. The quality of nursing home food and food service was examined using a multidimensional theoretical model integrating consumer and provider perspectives.

The importance of staff emerged strongly in this study in all five themes. Even the theme, Choosing Surroundings, required the assistance of staff for serving residents’ trays in their own rooms or gathering them together in the dining room. Dietary staff and nursing assistants were the catalysts for a pleasurable atmosphere as they served and chatted with residents, ensuring that food preferences were honored. Intertwined with the dimension of staff is the dimension of care. Residents also wanted a pleasant milieu with music and companionship at meals. They also wanted food to be served at the right temperature and on time. Communication was also an important dimension in all five themes, including issues of choice, interaction, problem correction, eating location, and availability of adequate food all rested on resident-family-staff communication.

Staff must be quick to offer residents help with preparation of the food already on residents’ trays, opening milk and yogurt cartons, buttering bread, or removing a baked potato from foil so that residents can eat while food is hot. Consistent care is vital, and residents’ likes and dislikes should be elicited, prominently displayed for staff, and honored, meal after meal.

B Evans, N Crogan, J Armstrong Shultz. Quality dining in the nursing home: the residents’ perspective. J Nutr Elder 22(3):1-16 (June 2003) [Correspondence: Bronwynne C. Evans, Washington State University College of Nursing, 2917 Ft. George Wright Drive, Spokane, WA 99224. E-mail: evansb@wsu.edu]

COPYRIGHT 2003 Frost & Sullivan
COPYRIGHT 2003 Gale Group

HOW TO APPLY FOR RECIPROCITY IN ANOTHER STATE

What is reciprocity - By Federal and State Laws, you must pass a State prescribed course and test in order to work as a nursing assistant in a nursing home. You also cannot work as a nursing assistant in a nursing home in any state unless you are approved by that state.

If you already are Licensed, Certified, Registered or State Approved in your own State and want to move to another state, you will need to request reciprocity. This means that you are asking the new state to recognize the approval you received from your home state.

How to request reciprocity

1. The first step is to contact the Nurse Aide Registry in your home state and request a “Application for Enrollment By Reciprocity”. Ask them if you should send the completed form to them or to the state to which you are moving.

2. Then contact the other state and ask them the same thing. Some nursing assistants have been able to fax their request directly to the state they are moving into rather than with their home state. Do not take chances, ask. Be sure to get the name of those who talk with you and their phone numbers. Call them by name while you are talking so they remember you.

3. If the agency in your new state says it is acceptable for you to fax or mail info, then do this right away. Be sure to clarify the fax number and the mailing address. Then fax or mail your info to the attention of the person you spoke to. Ask them what items you will need to fax or mail but be prepared to send at least the following:

Copy of your Social Security Card
Copy of your drivers license (or other photo ID)
Copy of your present State approval
Copy of a recent pay stub or something to document that you have worked in a nursing home in the past two years.
Tell them where you are moving from and where to and where they can send the new card.
They may ask for other info as well

4. When you send your info, include a brief note to thank the person who took time to talk with you and ask them to call you if they need more information.

Automated lines

When you call, you may get an automated line. Most automated lines are free 800 numbers and can provide some good information. Do listen and be prepared to write down numbers, but also always try to get a connection to a real person.

HOW TO FIND A TRAINING OR TESTING PROGRAM IN YOUR AREA

Every nursing home in the country must be prepared to provide for training and testing for their nursing assistants, and should have information about the training and testing sites that are local to you. In some states, the training and testing is conducted by nursing homes, some use community colleges and still others use independent agencies. The best way to get information about the training and testing programs in your area is to talk to a trainer or DON in your area. If this does not provide the needed information, contact the Area Agency on Aging or the NATP agency in your state.

A stroke is caused by a disruption of the blood flow to the brain. This disruption causes the death of brain cells.

There are four types of strokes:

TIA: A transient ischemic attack is a temporary attack that may last only a few minutes or up to 24 hours. Sometimes it is so mild that it goes unnoticed. A TIA is a warning that a more serious stroke may occur.
RIND: A reversible ischemic neurologic deficit is similar to a TIA, except the symptoms last from several days to a week. As with a TIA, the damage usually clears completely or is minimal. However, the likelihood or a major stroke is great.
SIE: A stroke in evolution is a stroke in the process of taking place. There is a gradually increasing weakness on one side of the body.
CS: A complete stroke exhibits all of the signs and symptoms of a stroke.

The symptoms of a stroke can vary greatly-here are some of the most common:

dizziness
poor coordination
headache
mental confusion
aphasia (difficulty speaking)
weakness in one hand or on one side of the body
unconsciousness

Your residents who have had a stroke need special nursing care for the complications related to paralysis or partial paralysis. Consider the following when caring for a stroke resident:

Decubitus ulcers
Special mattresses and pads, proper skin care and frequent turning can prevent or minimize the occurrence of pressure ulcers. Always follow your facility’s policies and procedures concerning decubitus ulcers.
Contractures
Proper body alignment must be maintained to prevent contractures. Take special care to maintain residents’ feet in their normal position.
Pneumonia
Frequent turning and position changes move the fluid that collects in the lungs. Great caution should be taken when feeding a partially paralyzed resident to prevent aspiration pneumonia. Encourage the resident to cough often, as this reduces the amount of mucus in the lungs.
Urinary and fecal incontinence/retention
This is a very common result of a stroke. Recording intake and output and bowel habits permits early intervention before a problem becomes too serious. Get the resident on a regular toileting schedule or offer the bedpan at regular intervals.
Falls
Stroke residents have a distorted sense of the location of the affected side of the body. Assist the person with ambulating and transferring until you determine it is safe without you.

Physical, occupational, and speech therapy can greatly improve the status of a resident who has had a stroke. In addition, family members and staff have a tendency to do too much for stroke residents. Although you should help with things they are unable to do on their own, the more stroke residents are encouraged to do, the better they feel and the more complete the recovery.

Source

Depression is a disease that involves chemical changes in the brain and impacts the entire body, not just the mind. People who suffer from depression often lose or gain weight, have poor sleep habits, and lack energy.

Almost everyone feels sad, lonely, or unhappy at times. But a person suffering from depression feels this way all or almost all of the time. With the exception of anxiety, depression is the most common mental disorder in the United States.

Many nursing home residents suffer from depression. Symptoms of the disease usually develop slowly over a period of days or weeks. Very early signs of depression include decreased physical and mental activity, and feelings of sadness, irritability, and anxiety.

When people are clinically depressed, they may exhibit any of the following symptoms:

Inability to concentrate
Complaints of physical illness
Inability to feel pleasure or other emotions
Increase in self-critical thoughts
Increase in sleep disturbances. It may be difficult to fall asleep, stay asleep, and wake up at the usual time. May feel excessively tired after a full night’s sleep
Changes in appetite and eating habits
Feelings of helplessness and hopelessness; thoughts or threats of suicide.
Personality changes, such is irritability or introversion
Increase in sexual promiscuity or loss of sexual interest
Increas in use of alcohol or drugs.

If many or most of these symptoms persist for longer than two weeks, there is a good chance that the diagnosis will be clinical depression. Next week, we’ll discuss causes, diagnosis, and treatment of depression.

For LTC Nursing Leaders

Violating the top OSHA citation may cost your SNF money

Published December 2004

If the Occupational Safety and Health Administration (OSHA) knocks on your facility’s door tomorrow, do you know where inspectors’ trained eyes will turn? Although ergonomics is a big focus for OSHA during nursing home inspections, ergonomics violations are not the top trouble spot for skilled nursing facilities (SNF).

Instead, citations related to the bloodborne pathogens standards head OSHA’s nursing home inspection list-by a long shot. Between October 2003 and September 2004, OSHA cited violations under the bloodborne pathogens standard a total of 305 times during 120 inspections as of November, according to OSHA’s Web site. SNFs paid a total of $127,767 for these citations.

“Keep in mind that those statistics [show citations by] federal OSHA only. There are 24 states that enforce their own occupational safety laws, and 26 states have federal OSHA offices enforcing safety laws,” says Sam Church, BA, MA, managing director of The Safety Department, a consulting agency in Pittsburgh.

Although the bloodborne pathogens standard is broad, don’t feel overwhelmed. You already know how important documentation is for reimbursement and resident care, and OSHA compliance is no different. The following documentation gaffes can be cause for citation in OSHA’s eyes, according to Church:

* Omitting a standard requirement from your written policies and procedures. Your exposure control plan must address all bloodborne pathogens standard requirements. “Even if you’re doing [every safety procedure] right, if it’s not written down correctly, it’s a violation,” warns Church.

* Training lapses. If your facility fails to educate employees who were absent from the facility’s annual required bloodborne pathogens refresher training-and you don’t have proof that your SNF trained those employees at another time-OSHA could issue a citation.

* Employer certifications. This important component is a required element of your policies and procedures. An individual must sign the policies and procedures to certify that the facility in fact adheres to its written practices and provides adequate training. That way, OSHA can hold a person accountable for the organization’s actions, Church explains. “This is similar to what you’ve seen with the Sarbanes-Oxley Act.”

* Policies and practices don’t match. If staff fail to practice an element of your facility’s policies and procedures, it is also a violation.

But that’s not all you should document. The federal OSHA standard requires you to assemble a staff committee to review bloodborne pathogens safety, such as testing safer needle devices or evaluating needleless techniques, says Libby Chinnes, RN, BSN, CIC, infection control consultant in Charleston, SC.

Keep a record of your staff committee’s meetings and actions. Many facilities document this information as an addendum to their exposure control plans, Chinnes says. They include which safety devices staff reviewed, which staff participated, and which devices they adopted.

Source: Adapted from Briefings on Long-Term Care Regulations (December 2004), published by HCPro, Inc.