Dining Practice
Standards 101:
Part 2
Contributed by Rose Hoenig, RD, CSG. LD, and Carol S. Casey, RD, CDN, LDN, SFPM, FSM
Review Date 12/11
G-1753
New Standards of Practice
These nationally agreed upon new
food and dining standards of
practice support individualized
care and self-directed living vs
traditional diagnosis-focused
treatment for people living in
nursing homes. The document
includes the new Standards of
Practice.
Standards of Practice
Individualized Nutrition Approaches/Diet
Liberalization
Individualized Diabetic/Calorie-Controlled
Diet
Individualized Low-Sodium Diet
Individualized Cardiac Diet
Individualized Altered Consistency Diet
Individualized Tube Feeding
Individualized Real Food First
Individualized Honoring Choices
Shifting Traditional Professional Control to
Individualized Support of Self-Directed Living
New Negative Outcome
10 Dining Practice Standards
Reflects current thinking and consensus,
which are in advance of research
Reflects evidence-based research
available to date
The current thinking portions of each of
the new Dining Practice Standards
represent a list of recommended future
research
http://www.pioneernetwork.net/Provide
rs/DiningPracticeStandards/
It Is All About F-Tag 281
F281 §483.20(k)(3)
(3) The services provided or
arranged by the facility must—
(i) Meet professional standards of
quality and Intent §483.20(k)(3)(i):
The intent of this regulation is to
assure that services provided meet
professional standards of quality, in
accordance with a specific definition
F-Tag 281 (cont’d)
Interpretive Guidelines
§483.20(k)(3)(i):
“Professional standards of
quality” means services that are
provided according to accepted
standards of clinical practice
Standards may apply to care
provided by a particular clinical
discipline or in a specific clinical
situation or setting
F-Tag 281 (cont’d)
A professional organization,
licensing board, accreditation
body, or other regulatory
agency may publish standards
regarding quality care practices.
Recommended practices to
achieve desired resident
outcomes also are found in
clinical literature.
F-Tag 281 Standards of Practice
Standards are published by
professional organizations, such as:
Academy of Nutrition and Dietetics
American Medical Association
American Medical Directors
Association
American Nurses Association
National Association of Activity
Professionals
National Association of Social
Work
(Cont’d)
F-Tag 281 Standards of Practice
Based on:
Current manuals or textbooks on
nursing, social work, physical
therapy, health care guidelines,
etc
Clinical practice guidelines
published by the Agency of
Health Care Policy and Research
Current professional journal
articles
Interpretive Guidelines
§483.20(k)(3)(i):
If a negative resident outcome is
determined to be related to the
facility’s failure to meet
professional standards and the
team determines a deficiency has
occurred, it should be cited under
the appropriate quality of care or
other relevant requirement
Elements of Each Dining Standard
Basis in current thinking/research
Relevant research trends
Recommended course of practice
References
“All Decisions Default to Personal Choice”
Dining Practice
Standard 1
Individualized
Nutrition Approaches:
Diet Liberalization
Liberalized Diets Research
Evidence-based research
continues to support that
therapeutic diets are
detrimental at worst,
neutral at best for the
elderly
Liberalized Diets Research
Restrictive diets are a frequent
cause of weight loss
Physicians are encouraged to
liberalize diets
Medical needs are balanced with
quality of life
Prevention of weight loss is viewed
as a priority
Resident’s goals and wishes are
followed
Letting Go of Therapeutic Diets
Fear of regulations may fade
over time
Individualized and residentinformed choice frequently
found in regulations
It is our duty to educate
residents of the consequences,
good or bad, of their choices
then allow them to make
choices
Dining Practice
Standard 2
Individualized Diabetic/
Calorie-Controlled Diet
Research on Diabetic Diets
Intensive treatment of diabetes
sometimes is not appropriate for all
individuals in the long-term care (LTC)
setting
No evidence to support noconcentrated sweets, no-added-sugar
diets for older adults in LTC—using
medication rather than dietary
changes can enhance the joy of eating
AMDA: Target of A1c 7–8 discourages
use of sliding scale insulin
Dining Practice
Standard 3
Individualized
Low-Sodium Diet
Research on Low-Sodium Diets
May benefit some individuals, but in
frail elderly more lenient blood
pressure goals and more lenient diets
are needed
A liberal approach sometimes is
needed to maintain nutritional status
Typical 2-gram sodium diet achieved
only modest effect on blood pressure
and is not shown to improve
cardiovascular outcomes in LTC
residents
Dining Practice
Standard 4
Individualized
Cardiac Diet
Research on Cardiac Diets
Diets are not shown to improve
control or affect symptoms
Dietary Guidelines for Americans
and/or DASH diet can achieve goals
Important to balance restrictions
with adequate nutrition
Aggressive lipid reduction in LTC is
more effectively achieved through
use of medications
Dining Practice
Standard 5
Individualized Altered
Consistency Diet
Research on Altered Consistencies
Swallowing abnormalities do not
necessarily require modified texture
Collaborate with doctor, speech
pathologist, registered dietitian, and
other professionals
Look beyond symptoms to underlying
causes to avoid excessive
modification of food/fluid
Sometimes it is necessary to
evaluate tolerance of aspiration risk,
compared to the slow process of
wasting away
Dining Practice
Standard 6
Individualized
Tube Feeding
Research on Tube Feedings
Is not an automatic step when other
strategies have failed
Does not ensure patient’s comfort or
eliminate aspiration risk (abdominal
distention, diarrhea, and restricted
movement)
Is not always appropriate for
advanced disease states
What does/did the patient want?
Research on Tube Feedings
Tube placement will not resolve
oral secretions/gastric content
issues
Weight gain from tube feeding is
not shown to correlate with
improved clinical outcomes
Decreased socialization and
depravity of the social
experience at mealtimes are
strong considerations by many
(Cont’d)
Enteral Feeding Decisions
Patient Rights and Informed
Consent/Refusal Across the
Healthcare Continuum, 2005
Mayo Clinic Proceedings
See pages 52–56 of Dining
Practice Standards for Enteral
Algorithm for Decision Making
Arguments for placing a tube for feeding
include improving nutritional status.
Studies in the elderly with dementia have
shown little to no improvement in weight.
Tube feedings also are considered for
wound care as a means to improve wound
healing. Data over a 6-month follow-up have
shown no impact on pressure ulcers or
infections associated with wounds.
Feeding tubes do not improve quality of life.
An association with physical or psychosocial
discomforts related to the tube feeding is a
negative consideration.
Dining Practice
Standard 7
Individualized
Real Food First
Research on Real Food First
Provide naturally soft, smooth
texture before pureed foods when
possible (yogurt, puddings, ice cream,
and vegetable soufflés)
Create meals comparable to home
Select from approved sources from
family and friends, gardens
Serve food before supplements
Choose homemade before commercial
Use flavor enhancers
Flavor Enhancement
Taste and smell losses occur with aging, which can
decrease food enjoyment, reduce food
consumption, and negatively influence nutritional
status.
Flavor enhancers can compensate for the
diminished sensory function, which is a
contributing factor to impaired appetite and
decreased intake in the elderly.
What are flavor enhancers? They are food
additives commonly added to foods, designed to
enhance the existing flavors of products.
You can use commercially manufactured flavor
enhancers, but the best flavor enhancers are
those found in an ordinary spice rack or pantry.
You can make bland, tasteless meals a thing of the
past with the improvements of culture change and
dining practices.
Examples of Flavor Enhancers
Spices and herbs: Basil, garlic, dill, rosemary,
lavender, mint, pickling spices, thyme, sage, etc
Seasonings or flavor enhancers: Ancho
powder, chili powder, Accent® (monosodium
glutamate [MSG]), Spike® (hydrolyzed
vegetable protein), anchovies and anchovy
paste, balsamic vinegar, Bon Appetit® Seasoning
Salt, capers, Chef Paul Prudomme’s® Seasoning
Blends®, Chile peppers, citrus fruits (juice and
zests), grapes, molasses, Old Bay® Seasoning,
onions, pepper, peppermint oils and extracts,
sugar, date sugar, Tabasco®, tahini, truffle oil,
cooking wine, etc
Resource:
http://whatscookingamerica.net/herbs.htm
Staff Creativity Combines
With Resident Choices
The standard cooking techniques,
recipes, and bland foods are no longer
the Gold Standard
Staff must bring creativity to food
preparation, trying new recipes, new
cooking techniques and food
combinations, and flavor
enhancements
Staff and residents must form an
alliance in menu choices and selections
Additional Factors to Assess
for Decreased or Poor Appetite
Diagnostic or assessment factors that
could impair appetite
Active diseases and conditions that have
the potential to negatively affect
appetite
Potential food and drug implications
Surgical interventions—anesthesia has
a tendency to interfere with appetite
Environmental issues, including texture
and appearance of food