This week’s “Ftag of the Week” on the CMSCG Blog is part of the Food and Nutrition Services regulatory group, F808 Therapeutic Diet Prescribed by a Physician. This regulation is meant to ensure that nursing home residents receive and consume foods that are in the appropriate form and/or have the appropriate nutrient content to support the resident’s needs.
The regulation itself and the associate Interpretive Guidance are both short, but noncompliance with the requirements of this regulation can lead to a negative outcome, including an unfortunate harm-level deficiency or even an Immediate Jeopardy situation.
The regulation for F808 requires that therapeutic diets are prescribed by the attending physician, or to the extent that it is allowed by a State’s law, the attending physician may delegate the task of prescribing the resident’s diet to a registered or licensed dietitian. If this physician delegates this task, he/she is still responsible for the resident’s care and must supervise the dietitian. This continued oversight and responsibility, per the Interpretive Guidance, gives the physician the ability to modify a diet order if it became necessary.
Types/Forms of Diet
The regulation defines two types of diets at F808, a therapeutic diet and a mechanically alerted diet.
A therapeutic diet is a special diet ordered by a physician/delegate with one or more of the following purposes:
- The diet is part of a disease or clinical condition’s treatment
- The diet is meant to eliminate/decrease specific nutrients in a resident’s diet
- The diet is meant to increase levels of specific nutrients in a resident’s diet
- The diet provides food in a form that a resident is able to eat, such as a mechanically altered diet
This last bullet regarding a therapeutic diet prescribed to ensure it is in a form that a resident can eat is a common systems issue. Mechanically altered diets are diets where the texture of the food has been altered based on the specific physician’s order.
During the Initial Pool process, surveyors review Nutrition as one of the care areas of focus, and during the interview process, residents will be queried as to whether they are on a special diet, including an altered consistency, if they have difficulty swallowing food and other inquiries that may lead a surveyor to add them to the survey sample. Don’t forget that unplanned weight loss will be looked at – what do you think a surveyor will see in your dining room when a resident with an order for a pureed diet is attempting to eat that sandwich that is clearly not on his/her meal ticket? Speaking of the dining room, don’t forget about the dining observation, as there are plenty of opportunities to see whether residents are receiving the appropriate items and the assistance they may need.
Citation Example 1 – S/S: J – Immediate Jeopardy
A resident with a physician order for a puree diet of ground meats only was served a grilled cheese sandwich. The surveyor asked the nurse manager if the resident should have that sandwich and she responded that the resident liked grilled cheese sandwiches and had them in the past. Multiple staff were interviewed and ultimately, a Registered Nurse told the surveyor that she was aware of the diet, but still provided the resident with the sandwich, which resulted in an Immediate Jeopardy situation.
Citation Example 2 (S/S: J – Immediate Jeopardy)
Another facility was also cited at an Immediate Jeopardy level when a surveyor watched meal service and saw a resident chewing and spitting out pieces of chicken and chicken skin. He checked the resident’s tray ticket and saw that it indicated the resident should have received a ground diet.
Both of these actual citations provide a strong reminder about the importance of ensuring that there is a system in place for tray accuracy and that responsible staff receive education about their responsibilities. While it was not the situation for either of these cases, it is currently the case that many nursing homes are still not having communal dining due to COVID-19. What could have happened if the residents received these inaccurate meal trays in their rooms without appropriate supervision may have resulted in an even worse outcome.
There are also opportunities for issues related to therapeutic diet for residents with restrictions for conditions such as diabetes or renal issues. The following citation is a good examples of an issue identified related to these types of diets.
Citation Example (S/S: E)
A facility failed to ensure that fluid restrictions were in place and monitored per physicians orders for multiple residents reviewed for the same. The following observations were made:
- Resident with order for fluid restrictions observed consuming a minimum of 8 oz of water from a pitcher at a table, but no documentation was made that any fluids were consumed during the entire shift. CNA queried about who could receive water and responded that anyone except residents who needed thickened fluids could have water. The staff member was unaware of how many ounces of water the mugs provided to residents held.
- Another resident was observed in bed drinking water from a large mug. Review of the resident’s record revealed multiple weight fluctuations pre- and post- dialysis and there was no documentation about the resident’s fluid breakdown.
As you are aware, the provider matrix that needs to be given to the survey team requests information about residents who are receiving dialysis services, so it is to be expected that residents who are on fluid restrictions will be added to your survey sample.
The bottom line is that a facility needs a system in the kitchen, if meals are not plated on the units, for monitoring meal tray assembly to ensure that the food/fluid contents are in agreement with the ordered diet and what is placed on the meal tray. If you are plating on the units, the server needs to fully read the ticket and ensure that the items provided are consistent with the ordered diet.
Nursing is not off the hook – there should be a system in place for validating that the food/fluids served to each resident is consistent with the ordered diet as well as addressing any fluid restrictions. Everyone needs to be reading the meal ticket!
What is a facility’s best asset in achieving ongoing compliance with this regulation?
An educated staff both in the kitchen and on the nursing units who understand the reasons for altered diets, fluid restrictions, etc., know how to assemble a meal tray and how to check the accuracy before serving food/fluids to a resident.
Needless to say, we should be assessing staff knowledge of these systems during routine observations meal service in all dining areas and resident rooms.