Malnutrition and dehydration are common concerns in the elderly population, particularly in situations with multiple comorbid conditions.  Diagnoses such as diabetes, chronic renal disease, congestive heart failure, Alzheimer’s, and other dementias are exacerbated, and elderly patients become more susceptible to falls, pressure injuries, deep vein thrombosis, and infections as a result.  Comprehensive medical record documentation is critical in demonstrating quality care and defending against allegations of malnutrition and dehydration.

On-site nursing home surveys were put on hold during the pandemic.  An analysis of on-site surveys since they resumed in January 2022 revealed the fourth most frequently citied deficiency was F684-Quality of Care, which includes nutrition and hydration.  Staffing shortages during the pandemic have been alleged to contribute to dehydration and malnutrition in the nursing home population.

The causes of weight loss and malnutrition in elderly patients are referred to as the “9-Ds”:  Disease, Dysphagia, Diarrhea, Depression, Dementia, Dentition, Dysgeusia, Dysfunction, and Drugs.  The sense of thirst diminishes with age, making the elderly more prone to dehydration.  Unfortunately, symptoms of dehydration, such as dry mouth, fatigue, and dizziness, often go unrecognized.  With these risk factors, it is important that residents are encouraged to eat and drink throughout the day, and that these interactions and intake are consistently documented.

The Centers for Medicare & Medicaid Services (CMS) provides the following guidelines for the Long-Term Care Survey Process in evaluating nursing home residents’ status.  The Hydration Critical Element Pathway and the Nutrition Critical Element Pathway include, but are not limited to, the following areas for medical record review:

• New or existing conditions or diagnoses that affect overall fluid intake:
  • Malnutrition, dehydration, cachexia, or failure-to-thrive.
  • Problems with teeth, mouth, gums, or swallowing problems.
  • Decreased kidney function or urine output, renal disease.
  • Decreased thirst perception, increased thirst, change in appetite, anorexia.
  • Cognitive or functional impairment (e.g., dysphagia, dependency on the staff for ADLs, inability to communicate needs).
  • Terminal/progressive conditions
  • Constipation, impactions, or diarrhea.
  • Pressure ulcers and other chronic wounds, fractures.
    COPD, pneumonia, diabetes, cancer, hepatic disease, CHF, infection, fever, nausea/vomiting, orthostatic hypotension, hypertension.
  • Psychiatric concerns, significant changes in behavior or mood.
  • Lethargy/confusion.
• Identification of underlying risk factors
• Significant changes in condition and assessment of such within 14 days
• Assessment of hydration status, including baseline and calculation of fluid needs
• Assessment of nutritional needs, including calories, protein needs, desired weight range
• Lab values for hydration: e.g., BUN, creatinine, serum sodium
• Lab values for nutritional status: e.g., albumin and pre-albumin, transferrin, retinal binding protein
• Medication review for impact on food intake
• Interventions implemented, such as IV fluids
• Staff monitoring/documentation of fluid intake and food/supplement intake
• Weight monitoring
• Care plan and resident response to plan

Training of all staff on appropriate documentation is critical, particularly in the current environment of high employee turnover.  Staff must be aware of the importance of recording all interventions with residents in relation to nutrition and hydration, including any refusal by a resident to comply with recommendations.  Excelas’ medical analysts have extensive experience in reviewing medical records unique to long-term care settings.  Our medical chronologies and associated reports can assist administrators in preparing for surveys or assessing staff training needs and in preparing counsel for the defense of claims and litigation.  Contact us today to discuss your medical information management requirements.