By Mary Ellen Posthauer RDN, CD, LD, FAND

Frequently I am asked to review medical records to determine if an individual’s pressure ulcers failed to heal because of inadequate or inappropriate nutritional care. The majority of the cases involve long-term care facilities and the patients are older adults who had unintended weight loss (UWL) and pressure ulcers. After devoting 35 years as a consultant dietitian to nursing homes, I am well aware of the challenges faced by providers as they strive to provide care for our frail elderly.

However, many times the medical record fails to reflect the care that was provided. Fluctuating weights are one of the most serious documentation concerns. Weight records may reflect a 5 percent loss in 30 days or 10 percent in 180 days, or insidious loss over time, but the decline is not acknowledged in the medical record.

The Centers for Medicare & Medicaid Services (CMS) considers UWL of this magnitude significant. My goal when reviewing the medical record is to determine if the weight loss was avoidable. Some of the questions I may ask in assessing the weight records include the following:

• Did the staff re-weigh the individual to assure the weight was accurate?
• Did the team assess for factors that may have precipitated the weight loss such as edema, fever, depression, and infections such as urinary tract or respiratory?
• Were the physician, family and dietitian notified of the weight decline?
• In the facility records daily food/fluid intake, does the percentage of consumption reflect a decline?
• Does the medical record reflect discrepancies?

For example, the weekly summary states “resident intake is good” but the intake record paints a different picture. It often seems that weekly summaries are just copies of what was written the previous week. New physician’s orders are often not reflected in the current summary. If there is an order for an oral nutritional supplement, is there documentation to verify it was offered and consumed? Food consumption forms often have blank spaces leading some litigators to decide that meals or supplements were not served or provided. In reality they may have been served but the saying “not documented not done” prevails.

When the medical record reflects the individual has UWL and a pressure ulcer, then the focus of my review is to determine how the facility intervened to resolve the problem. The medical record indicates the following:

1. Consultation by the registered dietitian (RD) with the individual to determine food preferences and honor those choices;
2. Interviews to identify possible causes for food/fluid decline such as chewing or swallowing problems, signs of depression, or decline in ability to self-feed;
3. Interventions initiated to correct the problems noted such as speech therapy, occupational therapy or social service consultation;
4. Nutrition assessment that includes specific energy, protein and fluid requirements based on the individual’s need plus the method used to determine estimated need ( i.e. NPUAP guidelines);
5. Any recommendations communicated to the physician such as request to individualize diet, consideration of supplement or multivitamin with vitamins, minerals, etc.;
6. Acceptance of recommendations, include date recommended and accepted;
7. Physician refusal of recommendations with rationale for decline;
8. Plans for monitoring weight- weekly until stable;
9. Weekly skin report that states specific nutrition interventions;
10. Defined and implemented nutrition interventions that are consistent with the individual’s needs and goals;
11. Acceptance or refusal by the individual of the nutrition interventions;
12. Alternate plans when interventions are declined or refused;
13. Discussions with the individual, family and team members about the progress or lack of progress with the recommended interventions;
14. Frequent and consistent documentation by the RD that reflects the improvement and/or decline in the individual’s nutritional status;
15. Review of the Advance Directives regarding nutrition and hydration;
16. Discussion of alternative methods of nutrition and hydration when individual refuses adequate intake and pressure ulcers fail to heal;
17. Provision of comfort/palliative care when alternative feeding route is declined.

When the medical records indicate that the facility evaluated the individual’s clinical and nutritional risk factors, defined and implemented interventions, monitored the impact of the interventions, revised the approaches as appropriate and the individual still did not achieve acceptable nutritional status for healing, the decline is considered unavoidable.

About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the American Dietetic Association’s Unintentional Weight Loss work group.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.