Malnutrition is a significant health issue, impacting functional status, psychosocial well-being, and overall quality of life.  Up to 50% of elderly patients are hospitalized due to malnutrition.  A review of skilled nursing facility MDS 5-day assessments revealed the increase of patients with or at risk of malnutrition has increased steadily from 16% in October 2019 to 42% through June 2023.

Comprehensive medical record documentation is critical in demonstrating quality care and defending against allegations of malnutrition.  Below are highlights of the informative presentation on malnutrition and its impact on patient care presented to the Excelas medical team by Jillian Frye, MDN, RDN, LD, of The Ohio State Wexner Medical Center.

Types of Malnutrition

Malnutrition occurs when the nutrients consumed do not match the nutrients the body needs.  This can result in either a lack of nutrients or an overabundance of nutrients.

Extended use of supplements can adversely impact nutrition.  For instance, a patient taking zinc supplements may develop a copper deficiency due to zinc reducing the amount of copper absorption.  Similarly, calcium can inhibit iron absorption, so these supplements should not be taken at the same time of day.

Why does malnutrition matter?

Malnutrition impacts quality of life and many aspects of patient care.  Examples of physical implications of micronutrient deficiencies include fatigue from anemia caused by B12, folate, or iron deficiencies, fatigue from low glycogen stores, vision problems from thiamine or vitamin A deficiency, hair loss from protein or micronutrient deficiencies, and dry/scaly skin from essential fatty acid deficiencies.  Patients can experience social implications from these symptoms as well.

Financially, patients with malnutrition tend to have more expensive care and longer hospital stays.  In skilled nursing, the CMS Patient Driven Payment Model (PDPM) focuses on quality of care and patient outcomes, and one critical area is nutrition.  Nutrition intervention can reduce hospital readmissions, which is a quality measure tied to SNF Medicare reimbursement.

Diagnosis of Undernutrition

Ms. Frye provided a review of a typical assessment in the inpatient setting.  Upon admission, nurses use 2 screening questions to determine whether the patient has intentionally lost weight and if the patient’s appetite is poor.  At inpatient institutions, a nutrition professional (registered dietitian or dietetic technician) is required to see all patients within one week of admission, and at some institutions patients who are over 65 years or have a BMI less than 18.5 are assessed within three days.  Dietitians perform a nutrition focused physical exam (NFPE) that look for things such as fat and muscle wasting, as well as micronutrient deficiencies that can manifest physically.  Other factors are also reviewed including NPO status, chronic illness, or social/environmental factors (homelessness, drug use) for possible contributions to malnutrition. Patients with certain conditions, such as cancer, celiac disease, and burn victims, often have poor nutritional status and require additional protein and nutrients.

Laboratory results are also considered in the assessment; however, some common tests are not necessarily a reliable basis for diagnosing malnutrition.  For instance, a low prealbumin may not reflect malnutrition, as anorexic patients often have normal albumin and prealbumin levels.  Inflammation can also affect albumin and prealbumin levels.  Albumin and prealbumin may correlate with malnutrition, but practitioners should not rely solely on these lab values.  Rather, this information should be considered as part of the overall assessment and can be used to recommend protein supplements or other interventions.

For patients who have intentionally lost weight, including those on Ozempic/other weight loss drugs, have had gastric bypass surgery, and are anorexic, the nutrition assessment and malnutrition diagnosis can be complicated.  GLP-1s impact the estimated energy needs calculations, and patients taking these drugs have higher protein needs.  With one in eight adults stating they have or are taking a GLP-1 drug, plus the proliferation of copycat drugs available through telehealth outlets, the assessment of a patient’s nutritional status using current standards by a medical dietician is essential.

Documentation of Nutrition Status

Training all staff on appropriate documentation is critical in acute and long-term care settings.  Staff must be aware of the importance of recording all interventions with patients and residents concerning nutrition, including any refusal to comply with recommendations.  Excelas’ medical analysts have extensive experience in reviewing medical records and our medical chronologies and associated reports can assist administrators in preparation for surveys or assessing staff training needs and in preparing counsel for the defense of claims and litigation.