Long Term Care & Pediatric Rotation
I completed my long term care (LTC) rotation at Whitestone Care Center and Dunmore Health Care Center, spending most of my time at Whitestone. Both these centers operate under the Saber Healthcare Group. This experience gave me an opportunity to work with many more residents and witness how each center was run under different management styles. The role of the RDN at these facilities is to monitor resident’s weights fluid intakes/outputs (I’s and O’s) and complete nutrition assessments upon entrance to the facility as well as quarterly and yearly. The RDN is critical in monitoring resident’s weight and fluids so they maintain adequate nutrition and hydration status and collaborate with nursing and dietary staff to maintain quality of life. During this time I completed nutrition assessments, participated in daily interdisciplinary morning meetings with staff, attended resident care plan meetings and got to know the facilities. During this rotation, I completed the objectives detailed below in bold headings. (Hour reporting form and checklist).
Reviewed the most recent state inspection results:
The most recent inspection results showed that Whitestone Care Center was in compliance with all regulations and they had addressed all deficiencies from their previous review. Licensed nursing homes are inspected annually by the Pennsylvania Department of Health, which makes sure they are in compliance with state and federal regulations. The survey takes several days, which I was able to witness while being at Dunmore. The surveyors arrived and stayed for most of the week, inspecting the facility, speaking with employees and requesting records. They observed the interactions between staff and residents, interviewed residents/family and audited medical charts, all while observing the facility for cleanliness, safety, and repair.
Demonstrated familiarity for the Minimum Data Set (MDS) and Care Area Triggers (CATs) & Care Area Assessments (CAAs) Protocols.
The minimum data set (MDS) is a standardized assessment tool used in long-term care facilities and by law, all residents in Medicare and/or Medicaid-certified nursing homes must have an MDS completed. The MDS assessment forms are completed for all residents within 14 days of admission, and then at quarterly and annual intervals, except in cases of a significant change in status, such as severe weight loss or initiation of tube feeding. These assessments are completed electronically and submitted by interdisciplinary staff such as social workers, nurses, and dietitians and are used for resident care planning, payments, monitoring care quality, and the Medicare/Medicaid Certification Process. Dietitians are responsible for filling out the the “K” or nutrition section of the MDS. (Carlson, 2018).
Section K and Care Area Triggers (CATs) and Care Area Assessments (CAAs).
When reviewing section K, data is gathered for the last 7 days, with the exception of height, weight, and weight change questions.
“A care area trigger (CAT) indicates that clinical factors exist that may or may not represent a condition that should be care planned.”
“When a resident’s status on a particular MDS item matches one of the CATs , then the related care area is triggered for further assessment.”
When a CAT is triggered, the triggers flag conditions that warrant further review and assessment.
“The care areas may be triggered by:
A single MDS response
A combination of more that one response option
A comparison of residents status on current assessment and prior assessment”
Care Area Assessments (CAAs)
“The completed MDS must be analyzed and combined with other relevant information to develop an individualized care plan. To help nursing facilities apply assessment data collected on the MDS, Care Area Assessments (CAAs) are triggered responses to items coded on the MDS specific to a resident’s possible problems, needs or strengths. The CAAs reflect conditions, symptoms, and other areas of concern that are common in nursing home residents and are commonly identified or suggested by MDS findings. Interpreting and addressing the care areas identified by the CATs is the basis of the Care Area Assessment process, and can help provide additional information for the development of an individualized care plan.”
The CAA’s for nutrition are: swallowing/nutrition status, feeding tubes, dehydration/fluid maintenance, lower or higher than normal BMI, significant weight changes up or down, parenteral/IV fluids, mechanically altered diet, therapeutic diet.
Finnie, M. (2016). Documentation: Writing Nutrition-related CAAs. [PDF].
When these areas are triggered the RDN reviews the information and writes a follow-up note, makes changes to the care plan where necessary, creates a nutrition intervention, implements it and documents it in the medical record.
Completed 5 MDS Quarterly Assessment
A large part of the dietitian’s job at a long term care facility is to complete nutrition assessments on residents when they first arrive, quarterly, annually and if there is a status change. Part of this documentation includes follow up/reassessment, interventions, monitoring and changes to care plans. The quarterly MDS assessments, as well as care plans, are included here.
Completed follow up/reassessment documentation in the electronic medical records system.
I had the opportunity to stay with a resident from admission to discharge. I participated in their full care from admission to discharge, reviewed their occupational therapy, physical therapy, and speech therapy notes. Including observing a speech therapy evaluation during meal rounds, and observing the making of a plan of treating which included upgrading the diet order from mechanical soft to regular with the speech therapist. Additionally, I was able to complete an MDS and the CAA, as well as a full nutrition assessment and care plan.
Attended meal rounds, recording caloric intake and recommended diet changes as needed
I attended meal rounds for lunch per the recommendation of my preceptor. At our facility no residents utilize the dining room on the first floor, therefore, I observed lunch service on the second floor. Also, not all residents like to eat in the dining room, therefore, I observed fewer people. Some residents are able to feed themselves, while others require help and/or encouragement. All the hospice patients observed were total feeds and required help eating. Family is also present at meals, and I saw three families visiting with loved ones. The meal service was efficient, all meals were delivered according to the meal cards and there were no issues noted. One resident was noted using an adaptive eating device. They were using a weighted utensil and no issues were noted with its use. Overall most residents appeared alert and eating well in general, with the exception of some hospice residents who appeared less alert and required a lot of encouragement to eat. There were no issues noted, and no diet changes were recommended at this time.
Attended medical and skin care rounds.
I attended the medical and skin care rounds. The medical rounds are performed by the attending physician who gathers all of the paper charts in the mid-morning and goes through all the latest developments and makes his recommendations. Then he continues with his rounds by seeing patients. In addition to that, each morning the head nurse of the facility prints out a 24-hr summary report, and goes over each residents case, new developments, medications/treatments and medical management of residents during clinical rounds. Then, this facility also has a traveling wound care physician, who comes in once per week on Tuesdays to perform skin rounds of all patients. This physician travels from one facility to another, taking care of many patients. The rounds begin by the physician meeting with his nurse, who accompanies him on rounds. The physician starts on floor one, and goes from room to room, checking his patients. He uses a headlamp, ruler and probes to assess wound healing and wound size and then he communicates his finding to the nurse who enters them in the EMR, and then he gives his recommendation for next treatment steps, the nurse follows them and re-dresses the wounds as necessary. This rounding continues to the second floor until the physician sees all his patients. Then the facility receives the wound care round physician notes.
Reviewed adaptive eating devices with the OTR and observed proper usage of the devices.
I was able to meet the occupational therapy team and speak about their interdisciplinary role at the facility. These practitioners meet with residents regularly and work on various tasks to improve activities of daily living. They have different tools at their disposal in the office as well as playing cards and other games to help residents improve their coordination and mobility, and help them achieve their movement goals. They often work on one item at a time and allow the resident to complete specific tasks, such as moving a block along a wire from left to right or play a card game. They also have some adaptive equipment in their office, thought the majority of the adaptive eating utensils are housed in the kitchen where they are sent up on their respective trays for resident use. During lunchtime meal rounds, as explained above, I was able to observe one resident using his adaptive, weighted eating utensils to feed himself, without any noted issues.
Coordinated the design of menus and modifications for therapeutic diets
I attended a resident meal council where residents come together to discuss upcoming menus, give their feedback and make requests for meals they would like to try. This meeting lasted about 30 minutes, during which time menu ideas were written down a menu was developed, including alternates. There was good feedback on regular meals, which the residents liked and were satisfied with. However, one of the issues that were noted was issues of night time snacks. The residents reported that they do not receive their snacks regularly in the evenings. The issue was noted and we discussed the findings during morning meeting and brainstormed ideas on ways to address the issue. Then, a form was developed with a sign-off for nurses to sign when they pass snacks in the evening to determine how many snacks are being given out.
Attended interprofessional meetings, developed nutrition care plans for the assigned residents and adjusted the care plans as needed
I attended the daily morning meeting with all department managers, followed by a clinical care meeting with the head of nursing and department nurses, where we discussed new resident developments ranging from resident activities to resident medical care and planning. During each morning meeting the RDN collects weights and I’s and O’s and shares with the team, which residents are missing critical weights and I’s and O’s and communicated this to the head nurse, who then delegates these tasks to her teams, in order for the weights to be entered in the EMR.
Additionally, I attended several care plan meetings both with residents alone, residents and their families, and with just resident families. The care plan meetings are designed for the interprofessional teams to discuss how resident care is proceeding, evaluating resident goals and determining if the goals are accurate, complete and relevant. Usually, care plans can last form 15 minutes to 1 hour or more. One care plan meeting required us to add a scoop dish and right angle spoon for the resident, while a second care plan meeting required no changes. Both are provided to show how care plan meetings are detailed.
Attended Risk Assessment Meeting, which involved a discussion about the new and updated Disaster Manual, which was reprinted and put into orange binders for each department. We also had simulation discussion about tornado protocol, which does not involve physically doing a tornado drill, but instead requires each department manager to discuss their plan of action before, during and after a tornado. Then each department head is tasked with going to their staff and asking them to verbalize their understanding of what to do during a tornado. The staff answers the questions, and if they are not satisfactory answers the department heads provide correct information. Each person encountered then signs off that they underwent the simulated tornado drill.
Finally, one of my projects here was to review every resident’s chart to make sure they have the correct diet orders on file. I reviewed all charts and wrote “dietary to nursing communications” to clarify the residents with incorrect information. This entailed handwriting a note with the intended order clarification for the nurse. Nursing then verifies the information and updates the resident’s chart and signs off on the nursing note and faxes the corrected information to the MD. In cases where the nurse is unable to do this, the MD verifies diet and makes corrections in the chart where necessary.
Monitored enteral and /or parenteral fed residents ensuring needs are met and
Discussed needed changes in nutrition support orders with other disciplines as needed.
I followed one resident through her chart, performed nutrition assessment and calculated her tube feed needs as well as visiting her while she was receiving her feedings. She receives bolus feedings, which are administered by the nurse. At the time of my visit she was receiving all of her ordered boluses and was tolerating them well. She met all of her needs through her tube feeding. Discussed feedings with the nurse and confirmed no changes necessary at the time of visit.
Reviewed a Modified Barium Swallow(MBS), Fiberoptic Endoscopic Evaluation (FEES) OR Video Fluoroscopic Swallow Study (VFSS) report and tracked the communication between the RD and the ST.
I reviewed one record of a patient that had a swallow study done and reviewed the speech therapy evaluation and plan of treatment for them. The patient was kept on a mechanical soft diet and continued to be monitored by the the speech therapist at the time of review. Additionally, more information and pictures detailing the procedure can be found under the MNT section.
Referred residents to other primary care providers as appropriate.
I had the opportunity to observe all aspects of care during my stay. All new residents are evaluated by all departments, including dietary, nutrition, physical therapy and speech therapy where needed. All residents are discussed during morning meetings and the nurses make all of the arrangements and referrals for other primary care providers. A wound care physician is contracted and comes to the facility regular. In one instance a resident was experiencing kidney issues and was referred out to nephrology. Overall, I was able to monitor patient activities and consults through the EMR.
Pediatric Rotation Checklist
I interned at the Children’s Hospital of Philadelphia, where I was placed in the endocrinology service. On Tuesday, I shadowed a hyperinsulinism specialist dietitian, who is responsible for managing care in this area. On Wednesday, due to a last minute change, I had the opportunity to shadow an oncology dietitian specializing in nutrition for bone marrow transplantation. On Thursday I followed an outpatient diabetes dietitian and observed her outpatient clinic and calculated a child’s protein and energy needs using the CDC growth charts and completed a CHOP pediatric case study. Finally, on Friday, I shadowed a diabetes and sports nutrition dietitian, who conducted carbohydrate counting/general diabetes education classes for the parents/family members of newly diagnosed diabetes patients. The below requirements were met with these materials.