Preventing Malnutrition and Dehydration in Senior Care Residents

Laura M. Cascella, MA, CPHRM

Malnutrition and dehydration are long-standing resident safety issues in senior care facilities, even though regulations and standards are in place to address these problems. Definitions of malnutrition vary, as do statistics related to prevalence; however, estimates suggest that about 20 percent of nursing home residents are malnourished, and even more are at risk.¹

Numerous and complex factors contribute to malnutrition and dehydration in senior care residents, which is likely why these issues persist. Additionally, these conditions can cascade into a host of other problems, including infections, pressure injuries, falls, depression, weakness, confusion, prolonged hospital stays, and mortality.²

Despite these complexities, senior care facilities have a legal and moral obligation to ensure that residents receive adequate nutrition and hydration. Doing so requires a comprehensive approach to identifying underlying factors that may contribute to malnutrition and dehydration as well as devising solutions that meet the needs of the resident population.

This article discusses numerous strategies in three broad areas: organizational environment and culture, education and training, and resident care and monitoring.³ These strategies can help senior care leaders, providers, and staff members evaluate their current approaches and identify quality improvement opportunities.

Organizational Environment and Culture

Structural and cultural issues within senior care environments — such as inadequate staffing, lack of supervision, and suboptimal dining conditions — can contribute to malnutrition and dehydration in senior care residents. In turn, these issues also can lead to resident harm and liability exposure. To address these concerns, consider the following strategies:

• Ensure your senior care organization is complying with any state-specific regulations and the Nursing Home Reform Act of 1987 (NHRA), including requirements for resident assessments, sufficient staffing, dietary services, and comprehensive care plans.
• Develop organizational policies and protocols related to nutrition and hydration that involve multidisciplinary collaboration from nurses, physicians, dietitians, dentists, certified nursing assistants (CNAs), and so on.
• Ensure that you have an adequate number of qualified staff members (e.g., CNAs) available during mealtimes to help residents who need assistance with eating and drinking.
• Verify that licensed nurses are appropriately staffed to provide oversight and guidance to CNAs or others who might be assisting patients with food and liquid consumption.
• Make sure staff members are available to ensure residents are seated at the proper height and properly positioned while eating, particularly if they have swallowing disorders.
• Consider residents’ personal and cultural food preferences, and try to provide a variety of appealing food options to meet the diverse needs of your resident population.
• Work to create pleasant and inviting dining settings, include opportunities for socialization, comforting surroundings, and appetizing and plentiful food choices.
• Limit excessive and loud noises in dining areas, and allow residents enough time to enjoy their meals. Give them the opportunity to choose where and with whom they’d like to sit.
• Make sure that food and beverage options are available 24 hours a day rather than only at standard mealtimes. Just like in broader society, senior care environments are diverse, and not everyone will have the same eating/drinking preferences and habits.

Education and Training

A well-educated and trained workforce is an asset for senior care organizations, particularly for providers and staff members who provide direct patient care and oversight. Without education and training, even the most comprehensive policies and procedures are meaningless. To ensure a robust training program that accounts for issues related to nutrition and hydration, consider the following strategies:

• Educate senior care providers and staff members about the conditions and circumstances that can lead to malnutrition and dehydration, such as poor oral health, depression, cognitive impairment, dysphagia, the side effects of certain medications, and diminished senses of taste and smell in older adults.
• Provide training opportunities for dietary leaders and chefs on meal preparation and presentation, especially for residents who require alternate food textures (e.g., soft or pureed diet).
• Make sure staff members who assist residents during mealtimes receive appropriate education and training on feeding residents as well as realistic numbers of residents to support during these times.
• Provide support and training to help family members better assist their loved ones with safe and adequate eating and drinking. Make sure family members know to whom they can direct questions or concerns about nutrition.
• Provide staff members with training on identifying and responding to choking hazards. All staff members working and assisting with feeding and supervising residents should be certified in basic life support so that they can quickly assess a choking event and intervene.
• Train your organization’s volunteers and nonclinical staff members on tasks that can help facilitate mealtimes and create an enjoyable atmosphere, such as carrying or setting up trays, opening containers, and engaging with residents socially.
• Make sure education and training for providers and staff members occur at hire and periodically thereafter to reinforce important information and concepts.

Resident Care and Monitoring

Senior care residents often have complex medical needs that might make them vulnerable to malnutrition and dehydration. Chronic medical and dental conditions and their treatments can result in diminished appetite, weight loss, difficulty chewing and swallowing, digestive problems, the inability to feed oneself, and so on. To proactively manage these risks, consider the following strategies:

• Work with medical providers to determine whether residents need nutritional supplements to help prevent malnourishment, and provide oversight to ensure they take their recommended supplements.
• Use screening tools as recommended by organizational policy to proactively identify residents who might be at risk for nutritional deficiencies.
• Ensure appropriate monitoring of residents’ weights to identify unintended significant weight loss (i.e., 5 percent in 1 month or 10 percent in 6 months) and to initiate a nutritional evaluation. If your organization is using electronic documentation systems, enable alerts related to resident weight loss.
• Collect data and information related to residents’ nutritional status, malnourishment, and dehydration to identify trends and commence quality improvement efforts.
• Address risk factors for malnutrition and dehydration with appropriate specialists who can help devise specialized care plans for residents. Specialists might include physicians, speech pathologists, dentists, etc. Examples of specialized needs that residents might require include changes to food preparation (e.g., soft or pureed diet) or proper fitting and subsequent adjustments to dentures.

In Summary

Malnutrition and dehydration continue to represent persistent and serious concerns in senior care facilities. To ensure high-quality care and reduce potential liability risk, senior care organizations should evaluate their organizational culture and environment, training and education initiatives, and resident care and monitoring protocols to ensure they are proactively identifying and addressing malnourishment and dehydration among their resident population.

Endnotes

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¹ Bell, C. L., Lee, A. S., & Tamura, B. K. (2015). Malnutrition in the nursing home. Current Opinion in Clinical Nutrition and Metabolic Care, 18(1), 17–23. doi: https://doi.org/10.1097/MCO.0000000000000130

² Burger, S. G., Kayser-Jones, J., & Prince Bell, J. (2000). Malnutrition and dehydration in nursing homes: Key issues in prevention and treatment. National Citizens’ Coalition for Nursing Home Reform, The Commonwealth Fund. Retrieved from www.commonwealthfund.org/publications/fund-reports/2000/jul/malnutrition-and-dehydration-nursing-homes-key-issues-prevention; Bell, et al., Malnutrition in the nursing home.

³ The strategies in this article are based on the following resources: Burger, et al., Malnutrition and dehydration in nursing homes; Nursing Home Abuse Center. (n.d.). Nursing Home Reform Act of 1987: Setting federal standards for nursing homes in the U.S. Retrieved from www.nursinghomeabusecenter.com/resources/nursing-home-reform-act/; Sweeney Law Firm. (n.d.). Malnutrition in nursing homes. Retrieved from https://sweeneylawfirm.com/content/malnutrition; Total Food Service. (2017, July 14). Textured food innovations sill revolutionize hospital nutrition. Retrieved from https://totalfood.com/textured-food-innovations-will-revolutionize-hospital-nutrition/

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