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:
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:
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.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.