Conquering Weight Loss - Idaho Health Care Association
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7/6/2021
Conquering Weight Loss
Ellen Turk RD,LD
1
Definition of unintended weight loss and why we care
Risk factors
CMS - Nutrition Critical Element Pathway
F692 regulation review
Outline Tips for obtaining accurate weights
Interventions for unintended weight loss
My resident had unintentional weight loss, now what?
Note: Case study and associated questions will be discussed
throughout the presentation
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7/6/2021
Unintended Weight
Loss
• Also known as involuntary weight
loss
• Definition: a decrease in body
weight that is not planned or
desired
• Occurs in up to 15-20% of older
adults
• Insidious weight loss: gradual,
unintended, progressive weight
loss over time
This Photo by Unknown Author is licensed under CC BY-NC-ND
3
Why Do We Care about
Unintended Weight Loss?
Associated with poor clinical outcomes including:
Increased morbidity
Increased mortality
Functional decline in Activities of daily living
Increased infections
Pressure ulcers
This Photo by Unknown Author is licensed under CC BY-NC-ND
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Case Study
Phyllis, an 82 YO Female is a resident at a local skilled
nursing facility
Current Diagnosis Include: COPD, respiratory failure, fall
with humerus fracture, DM, HTN, GERD, CKD
Current Medications: Aspirin, Albuterol, Metformin,
Oxycodone, Memantine, Zofran PRN
Recently has experienced decreased functional mobility
Recent lab values: Hgb 8.1, Hct 30.2, glucose 152, albumin
2.8
5
Per skin assessment: Stage 2
pressure ulcer to sacrum 2.0 x
1.5 cm
Current diet: RCS/regular
texture/thin liquids
Meal intakes x 1 week B: 34%,
L: 51% , D 49%
Case Study Admit weight: 145#
During resident interview
Phyllis reported:
Chewing problem r/t
dentures no longer fitting
Decreased appetite
Husband recently passing
away
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Phyllis’s Weight:
03/03/2020 145#
03/10/2020: 144#
03/17/2020: 137#
03/24/2020: 139#
03/31/2020: 137#
04/02/2020: 140#
Case Study 05/03/2020: 135#
06/01/2020: 130#
07/01/2020: 132#
08/04/2020: 137#
09/02/2020: 140#
7
Case Study
Questions
1. List 3 risk factors Phyllis has
for unintended weight loss
2. True or False: Polypharmacy
can contribute to
unintended weight loss?
3. True or False? As we age,
basal metabolic rate
decreases by 5% each
decade of life?
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7/6/2021
Risk Factors That Contribute
to Unintended Weight Loss
As we age physiological changes in our body lead
to changes in taste and smell and a decrease in
basal metabolic rate of 2% with each decade of life
Changes in hormone levels that control hunger and
fullness
Per the Academy of Nutrition and Dietetics, “By an
estimate 50 to 70 percent of residents in nursing
homes leave > 25% of their food uneaten at most
meals and 60 to 80 percent of residents have an
order to receive dietary supplements”
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9
Risk Factors That Contribute
This Photo by Unknown Author is licensed under CC BY
To UWL
Kidney disease
Congestive Heart Failure
Diabetes Mellitus
Parkinson’s
CVA
This Photo by Unknown Author is licensed under CC BY-SA-NC
COPD
Rheumatoid Arthritis
Multiple Sclerosis
ALS
Cancer
GI disorders (Crohn’s , pancreatitis, colitis)
This Photo by Unknown Author is licensed under CC BY-SA
10
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Risk Factors That Contribute to
UWL
Chewing problem
Swallowing problem
Impaired mobility
Dehydration
Pressure ulcers/nonhealing wounds
This Photo by Unknown Author is licensed under CC BY-NC-ND Hip fractures
Infection
11
Risk Factors That
Contribute to UWL
Depression
Dementia
Confusion
Social isolation
Anxiety
Bereavement
This Photo by Unknown Author is licensed under CC BY-SA-NC
12
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Risk Factors That Contribute
to UWL
Polypharmacy
Drugs interact with one another and
different foods
Causes side effects:
N/V
Anorexia
Sensory losses
This Photo by Unknown Author is licensed under CC BY
13
Medications
That Potentially
Lead to Weight
Loss
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Weight Loss and Covid19
Study published in JAMDA evaluated a 193 residents in a
skilled nursing facility
Over a 3 month period, Older adults on average weighed
3.68 lb. less after the implementation of nursing home
covid19 visitor and isolation restrictions
Recent JAMA from April 2021 evaluated 97 patients who
had acute smell loss with diagnosis of covid19
45.1% regained full recovery of olfaction after 4 months
96.1% regained full recovery of olfaction after 12 months
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15
How Does Weight Loss Relate to
CMS and Your Facility?
Weight loss is coded on the MDS
Section K
Weight loss is looked at as part of the Nutrition Critical
Element Pathway during survey
Pathway surveyors will use to determine if facility
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practices are in place to identify, evaluate and start
interventions to prevent maintain or improve the
residents’ nutritional status
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How Does Weight Loss
Relate to CMS and Your
Facility?
If facility fails to maintain
acceptable parameters of
nutritional status (including
weight) it can result in a
survey citation
F692 Tag
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Does anyone have experience with
an F692 citation and weight loss
that they would be willing to
share?
23
Regulation Review– F692: Nutrition and Hydration
• (Includes and gastrostomy tubes, PEG and PEJ and enteral fluids). Based on a
resident's comprehensive assessment, the facility must ensure that a resident:
• Maintains acceptable parameters of nutritional status, such as usual body weight or
desirable body weight range and electrolyte balance unless the resident’s clinical
condition demonstrates that this is not possible or resident preferences indicate
otherwise
• Is offered sufficient fluid intake to maintain proper hydration and health
• Is offered a therapeutic diet when there is a nutritional problem and the health care
provider orders a therapeutic diet
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F692 Regulation Review:
Nutrition and Hydration Status
• Regulation is divided into sections
• Intent
• Definitions
• Guidance
• Assessment
• Care Planning
• Interventions
• Monitoring
• Investigative Protocol
• Key Elements of Noncompliance
This Photo by Unknown Author is licensed under CC BY
• Deficiency Categorization
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F692- Intent of Regulation
The intent of this requirement is that the
resident maintains, to the extent possible,
acceptable parameters of nutritional and
hydration status and that the facility:
Provides nutritional and hydration care and
services to each resident, consistent with the
resident’s comprehensive assessment
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F692- Intent of Regulation
Recognizes, evaluates, and addresses the needs
of every resident, including but not limited to,
the resident at risk or already experiencing
impaired nutrition and hydration
Provides a therapeutic diet that takes into
account the resident’s clinical condition, and
This Photo by Unknown Author is licensed under CC BY-NC-ND
preferences, when there is a nutritional
indication
27
F692 Regulation Review:
Nutrition and Hydration Status
• Regulation is divided into sections
• Intent
• Definitions
• Guidance
• Assessment
• Care Planning
• Interventions
• Monitoring
• Investigative Protocol
• Key Elements of Noncompliance
This Photo by Unknown Author is licensed under CC BY
• Deficiency Categorization
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F692 :Guidance
• Early identification of residents with , or at risk
for, impaired nutrition or hydration status may
allow the interdisciplinary team to develop
and implement interventions to stabilize or
improve nutritional status before
complications arise
• Body weight and laboratory results can be
stabilized or improved with time, but may not
be correctable in some Individuals
• Intake alone is not the only factor that can
affect nutritional status
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F692: Guidance
Many factors can influence weight and nutritional status
as one ages
The body may not absorb or use nutrients as effectively
There may be changes in the ability to taste food or there
may be a decreased sensation for thirst or hunger
The resident’s medical condition can also affect how well
they maintain weight, such as changes in muscle mass ,
cognitive status , nearing end of life, or a disease process,
such as kidney disease or congestive heart failure, which
This Photo by Unknown Author is licensed under CC BY-SA
may cause the resident to retain fluids in the body
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F692 : Guidance
Failure to identify residents at risk for
compromised nutrition and hydration may be
associated with an increased risk of mortality
and other negative outcomes
Impairment of anticipated wound healing
Decline in function
Fluid and electrolyte imbalance/dehydration
Unplanned weight change
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F692 : Guidance
• A systematic approach can help staff’s efforts to
optimize a resident’s nutritional status. This process
includes:
• Identifying and assessing each resident’s
nutritional status and risk factors
• Evaluating/analyzing the assessment
information
• Developing and consistently implementing
pertinent approaches
• Monitoring the effectiveness of interventions
• Revising interventions as necessary
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F692: Guidance
Weight loss, poor nutritional status, or
dehydration should be considered avoidable
unless the facility can prove it has
assessed/reassessed the resident’s needs,
consistently implemented related care planned
interventions, monitored for effectiveness, and
ensured coordination of care among the
This Photo by Unknown Author is licensed under CC BY-NC-ND
interdisciplinary team
33
F692 Regulation Review:
Nutrition and Hydration Status
• Regulation is divided into sections
• Intent
• Definitions
• Guidance
• Assessment
• Care Planning
• Interventions
• Monitoring
• Investigative Protocol
• Key Elements of Noncompliance
This Photo by Unknown Author is licensed under CC BY
• Deficiency Categorization
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F692 : Assessment
A comprehensive nutritional assessment should be
completed on any resident identified as being at risk
for unplanned weight loss/gain and/or compromised
nutritional status
Through a comprehensive nutritional
assessment, the interdisciplinary team clarifies
nutritional issues, needs, and goals in the
context of the resident’s overall condition
Assessment must be completed by an RD
Out of scope of practice for CDM to “Assess” This Photo by Unknown Author is licensed under CC BY
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F692: Assessment
Completion of the RAI does not
remove the facility’s
responsibility to document a
more detailed resident
assessment
The assessment should identify
those factors that place the
resident at risk for inadequate
nutrition/hydration
This Photo by Unknown Author is licensed under CC BY-NC-ND
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F692: What should my Nutrition
Assessment Include?
The nutritional assessment may include the following information:
General appearance
Nutrition focused physical exam
Height
Weight
Including usual body weight
Interviews with key staff members
Food and fluid Intake
Estimate of calorie, nutrient and fluid needs and whether intake
is adequate to meet needs
Route of intake, snack patterns, food preferences, portion sizes
Fluid loss or retention
Laboratory values
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37
F692: What should my Nutrition Assessment
Include?
Altered Nutrient intake, absorption, and utilization
Cognitive function or decline
Difficulty with chewing or swallowing food
An inadequate amount of food or fluid, including insufficient tube feedings
Dining environment
Feeding ability
Adverse consequences related to medications
Diseases and conditions such as cancer, diabetes mellitus, advanced or uncontrolled
heart or lung disease, infection and fever, liver disease, kidney disease,
hyperthyroidism, mood disorders, gastrointestinal disorders, pressure injuries or other
wounds, and repetitive movement disorders (e.g., wandering, pacing, or rocking).
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3. True or False: Best practice per
CMS is for the facility to obtain
Case Study Phyllis’s weight 4x per year
Questions
4. True or False: 7.5% weight loss in
6 months is considered significant?
39
Does my facility
policy/process meet CMS
expectations for obtaining
weights?
Per F692 - Current standards of practice
recommend for facilities to obtain a
resident’s weight:
On admission/readmission
Weekly for the first 4 weeks upon
admission
At least monthly thereafter
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Does my facility policy/process meet CMS expectations for obtaining weights?
Additional circumstances may warrant more frequent weights
Significant change in condition
Persistent decline in food intake
Alteration in fluid/electrolyte imbalance
Weights may not be appropriate in individuals who are terminally ill or request
comfort care
If a weight cannot be obtained or a resident refuses, alternate methods can be
used to track
I.E. Midarm circumference
41
Interval Significant Loss Severe Loss
CMS 1 Month 5% Greater than 5%
Definition of
Unintended 3 Months 7.5% Greater than 7.5%
Weight Loss 6 Months 10% Greater than 10%
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How to Calculate Loss
% of body weight loss =. Weight Loss
____________ x 100
Original Weight
43
Phyllis’s Weight:
03/03/2020 145#
03/10/2020: 144#
03/17/2020: 137# 5. Calculate % weight
03/24/2020: 139#
loss at 1 month, 3
months and 6 months
Case Study 03/31/2020: 137#
04/02/2020: 140#
Questions 6. Did Phyllis have
05/03/2020: 135# significant weight loss
06/01/2020: 130# at 1 month? 3 months?
6 months?
07/01/2020: 132#
08/04/2020: 137#
09/02/2020: 140#
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Consider patients mobility and clinical condition when selecting
method to obtain weight
Standing scales
Chair scales
Wheelchair scales Tips for
Hoist scales
Bed scales Obtaining
Use a consistent scale for obtaining weights Accurate
Have a consistent staff member obtain weights
Weights
Weigh at the same time each month and same time of day
Balance scale to zero before and after each weight
45
Tips for Weigh patients in same clothing if possible ( light clothing preferred) ,
no shoes
Obtaining Empty catheter bags and drainage devices prior to weighing
Accurate If possible, remove prosthetic devices or weigh the prosthetic device
Weights individually and subtract from total body weight
Remove pillows, purses, jackets etc.
Calibrate scale per manufacturer's instructions
Immediately record weight
Follow appropriate infection control practices
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Does my facility policy/process meet CMS
expectations for obtaining weights?
Have procedure in place for tracking weight changes to
identify significant weight loss
Identify weight loss at 5% in one month,7.5% in 3 months
and 10% in 6 months
Have a policy and procedure in place for how your facility
obtains weights
This Photo by Unknown Author is licensed under CC BY-NC
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Does my facility policy/process meet CMS
expectations for obtaining weights?
Per CMS Regulations , there should be a documented
clinical basis for any conclusion that nutritional status
or significant weight change are unlikely to stabilize or
improve (e.g. physician’s documentation as to why
weight loss is medically unavoidable)
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F692 Regulation Review:
Nutrition and Hydration Status
• Regulation is divided into sections
• Intent
• Definitions
• Guidance
• Assessment
• Care Planning
• Interventions
• Monitoring
• Investigative Protocol
• Key Elements of Noncompliance
• Deficiency Categorization
This Photo by Unknown Author is licensed under CC BY
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Information gathered from the nutritional assessment and current
dietary standards of practice are used to develop an individualized
care plan to address the resident’s specific nutritional concerns
and preferences
Consult Advanced Directives if necessary
Note: DNR does not indicate a resident is declining other
appropriate treatments or services. It only indicates that the
F692: Care resident has chosen to be resuscitated if cardiopulmonary
functions cease
Planning
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F692: Care Planning
• The care plan must address, to the extent
possible, identified causes of impaired
nutritional status, reflect the resident’s personal
goals and preferences, and identify resident-
specific interventions and a time frame and
parameters for monitoring
• Goals should be measurable
This Photo by Unknown Author is licensed under CC BY-NC-ND
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7. Identify 2 possible root causes for
Phyllis’s uintended weight loss
Case Study
Questions
8. Identify 1 care plan goal for Phyllis’s
unintended weight loss
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F692: Care Planning
Examples of care plan goals may include, but are not limited
to:
A target weight range
Desired fluid intake
The management of an underlying medical condition (e.g.
diabetes, kidney disease, wound healing, heart failure, or
infection)
The prevention of unintended weight loss or gain
This Photo by Unknown Author is licensed under CC BY-NC
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F692 Regulation Review:
Nutrition and Hydration Status
• Regulation is divided into sections
• Intent
• Definitions
• Guidance
• Assessment
• Care Planning
• Interventions
• Monitoring
• Investigative Protocol
• Key Elements of Noncompliance
• Deficiency Categorization
This Photo by Unknown Author is licensed under CC BY
55
Case Study Questions
9. List 3 Possible Interventions for Phyllis’s Unintended Weight Loss
10. True or False: A resident may experience a decline in his or her ability to
chew food. If the underlying cause is poorly fitting dentures that are causing
pain or are loose in the mouth, the intervention of modifying the food texture
would not address the primary cause?
11. True or False: There is strong evidence to support the MD prescribing
Phyllis an appetite stimulant?
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F 692: Interventions for Unintended
Weight Loss
Interventions related to a resident’s nutritional status must be
individualized to address the specific needs of the resident.
Examples of care plan development considerations can include, but
are not limited to:
Diet Liberalization
Weight Related Interventions
Environmental Factors
Disease Process
Functional Factors
Food Intake
Medications
Maintaining Fluid and Electrolyte Balance
Feeding Tubes
TPN
57
F692 : Interventions
Diet Liberalization
• Minimize restrictions
• Provide preferred foods prior to supplements
• It is the responsibility of the facility to:
• Talk with the resident, their family and representative
(whenever possible) and provide information pertaining to
the risks and benefits of a liberalized diet
• Work with the resident’s physician and other nursing home
professionals (dietary manager, nurses, speech therapists,
etc.), using the care planning process, to determine the
best plan for the resident
• Accommodate the resident’s needs, preferences, and goals
This Photo by Unknown Author is licensed under CC BY
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F 692: Interventions for Unintended
Weight Loss
Interventions related to a resident’s nutritional status must be
individualized to address the specific needs of the resident.
Examples of care plan development considerations can include, but
are not limited to:
Diet Liberalization
Weight Related Interventions
Environmental Factors
Disease Process
Functional Factors
Food Intake
Medications
Maintaining Fluid and Electrolyte Balance
Feeding Tubes
TPN
59
For residents with unplanned weight loss, the care plan
should include nutritional interventions to address the
F692 :
underlying risks and causes based on the comprehensive
or any subsequent nutritional assessment
Interventions
The development of these interventions should involve
Weight
the resident and/or the resident representative to ensure
the resident’s needs, preferences and goals are
Related
accommodated. Interventions
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307/6/2021
F 692: Interventions for Unintended
Weight Loss
Interventions related to a resident’s nutritional status must be
individualized to address the specific needs of the resident.
Examples of care plan development considerations can include, but
are not limited to:
Diet Liberalization
Weight Related Interventions
Environmental Factors
Disease Process
Functional Factors
Food Intake
Medications
Maintaining Fluid and Electrolyte Balance
Feeding Tubes
TPN
61
F692 : Interventions
Environmental Factors
Consider the aroma, flavor, form and
appearance of food
Provide pleasant dining experience
Flexible dining schedules and meal times
Provide palatable, attractive, nutritious
meals
Use seasonings, serve foods at proper
temperatures
Ensure dining room and resident’s rooms
are appropriate for dining
This Photo by Unknown Author is licensed under CC BY-SA
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317/6/2021
F 692: Interventions for Unintended
Weight Loss
Interventions related to a resident’s nutritional status must be
individualized to address the specific needs of the resident.
Examples of care plan development considerations can include, but
are not limited to:
Diet Liberalization
Weight Related Interventions
Environmental Factors
Disease Process
Functional Factors
Food Intake
Medications
Maintaining Fluid and Electrolyte Balance
Feeding Tubes
TPN
63
A resident’s clinical condition may have a significant F692 :
impact on the types of interventions considered. The
facility is responsible for identifying relevant diagnoses Interventions
(e.g. wound healing, anorexia, end-of-life, etc.) and
appropriate interventions to address specific needs, as Disease
applicable Process
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327/6/2021
F 692: Interventions for Unintended
Weight Loss
Interventions related to a resident’s nutritional status must be
individualized to address the specific needs of the resident.
Examples of care plan development considerations can include, but
are not limited to:
Diet Liberalization
Weight Related Interventions
Environmental Factors
Disease Process
Functional Factors
Food Intake
Medications
Maintaining Fluid and Electrolyte Balance
Feeding Tubes
TPN
65
F692 : Interventions
Functional Factors
Functional Factors: Conditions that interfere with
resident’s ability to physically perform the task of eating
or drinking
Ability to use hands
Chewing problem
Swallowing problem
Ability to reposition oneself at a table
This Photo by Unknown Author is licensed under CC BY-ND
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F692 : Interventions
Functional Factors
Assess underlying cause to identify which
interventions may be most effective
Example: a resident may experience a
decline in his or her ability to chew food. If
the underlying cause is poorly fitting
dentures that are causing pain or are loose
in the mouth, the intervention of modifying
the food texture would not address the
primary cause
67
F692 : Interventions
Functional Factors
Functional Factor Interventions Include:
Adaptive equipment
Glasses
Hearing aides
Ensuring dentures are securely placed
This Photo by Unknown Author is licensed under CC BY
Restorative eating program
Meal assistance
Ensuring food and drinks are easily accessible
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F692 : Interventions
Functional Factors
Modify diet texture if appropriate
Modified texture may unnecessarily decrease quality of life
and impair nutritional status by affecting appetite and
reducing intake
Identification of a swallowing abnormality alone does not
necessarily warrant dietary restrictions or food texture
modifications. No interventions consistently prevent
aspiration and no tests consistently predict who will develop
aspiration pneumonia
For example, tube feeding may be associated with aspiration,
and is not necessarily a desirable alternative to allowing oral
intake, even if some swallowing abnormalities are present
https://www.google.com/search?q=puree+food&sxsrf=ALeKk00P4VPWQZfxlVfgRlaoYA1H5eq8ig:1625058004758&source=
lnms&tbm=isch&sa=X&ved=2ahUKEwj98PLotL_xAhXSgGoFHex0Ad4Q_AUoAXoECAEQAw&biw=1011&bih=681#imgrc=a
KFMbEsMYGIOoM
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69
F 692: Interventions for Unintended
Weight Loss
Interventions related to a resident’s nutritional status must be
individualized to address the specific needs of the resident.
Examples of care plan development considerations can include, but
are not limited to:
Diet Liberalization
Weight Related Interventions
Environmental Factors
Disease Process
Functional Factors
Food Intake
Medications
Maintaining Fluid and Electrolyte Balance
Feeding Tubes
TPN
70
357/6/2021
F692 : Interventions
Food Intake
Whole foods preferred to nutrition supplements
• If the resident is not able to eat recommended
portions at meal times, to consume between-meal
snacks/nourishments, or if he/she prefers the
nutritional supplement, supplements may be tried to
increase calorie and nutrient intake.
• Taking a nutritional supplement during medication
administration may also increase caloric intake
without reducing the resident’s appetite at mealtime
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F692 : Interventions
Food Intake
Fortify Foods
Offer Small More Frequent Meals
Provide between – meal snacks and
nourishments
Increase portion size of favorite foods
and meals
Provide Nutritional Supplements
This Photo by Unknown Author is licensed under CC BY-SA
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F692 : Interventions
This Photo by Unknown Author is licensed under CC BY-NC-ND
Food Intake
Fortify Meals
Fortified meals increase caloric density of
foods without increasing portion sizes
Add butter, mayo, peanut butter, sour
This Photo by Unknown Author is licensed under CC BY-SA-NC
cream, half and half, whipped cream,
cheese sauce, protein powder ,
evaporated milk, gravies
Establish a policy and procedure at your
facility for fortifying meals
This Photo by Unknown Author is licensed under CC BY-NC
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Ice Cream
Yogurt
Cottage Cheese
Smoothie
High Mashed potatoes
Avocado
Calorie/High Pudding
Protein Snack Milkshakes
Leftover desserts
Ideas Cream soups
Peanut butter
Hard boiled eggs
Sandwiches
Milk and cookies
Cheese stick
Egg Salad
Tuna Salad
This Photo by Unknown Author is licensed under CC BY-NC
75
Provide nutritional supplements
Preferable to use food first before
supplements
F692 : Interventions If possible , Liberalize diets and fortify meals
prior to supplementation
Food Intake Choose high calorie/high protein
supplements
“Get the best bang for your buck”
This Photo by Unknown Author is licensed under CC BY-SA-NC
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387/6/2021
F 692: Interventions for Unintended
Weight Loss
Interventions related to a resident’s nutritional status must be
individualized to address the specific needs of the resident.
Examples of care plan development considerations can include, but
are not limited to:
Diet Liberalization
Weight Related Interventions
Environmental Factors
Disease Process
Functional Factors
Food Intake
Medications
Maintaining Fluid and Electrolyte Balance
Feeding Tubes
TPN
77
F692 : Interventions
Medications
Medications may be helpful in improving a resident’s nutritional status.
Some ways medications may help a resident can be to increase appetite,
reduce acid reflux, or reduce nausea.
Some medications may have the unintended effect of impairing a
resident’s nutritional or hydration status and the resident may
experience a lack of appetite, nausea, dry mouth, or other unintended
effects.
A resident may require frequent sips of a drink during a meal if
they experience dry mouth. It may also be appropriate to consider
changing, stopping, or reducing the doses of those medications as
appropriate
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F692 : Interventions
Medications
• Appetite stimulants
• Appetite stimulants should
not be considered as a first-
line treatment for unintended
weight loss in the elderly
because of the lack of clear
evidence of their benefit and
the potential for significant
medication-related side
effects
This Photo by Unknown Author is licensed under CC BY-NC-ND
79
Megestrol (Megace)
• Side effects including blood clots, DVT, and toxic
reactions with impaired renal function and
increased mortality
• Should not be used for more than 12 weeks
because of risk of DVT
Mirtazapine (Remeron)
This Photo by Unknown Author is licensed under CC BY-SA
• Treats depression
Appetite • Can have sedative side effects that may lead to
increased risk of falls
Stimulants Dronabinol (Marinol)
• Contains the compound THC found in marijuana
• Also approved for treatment of N/V for
chemotherapy patients
Cyproheptadine (Periactin)
• Antihistamine
Marijuana
This Photo by Unknown Author is licensed under CC BY-SA
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F 692: Interventions for Unintended
Weight Loss
Interventions related to a resident’s nutritional status must be
individualized to address the specific needs of the resident.
Examples of care plan development considerations can include, but
are not limited to:
Diet Liberalization
Weight Related Interventions
Environmental Factors
Disease Process
Functional Factors
Food Intake
Medications
Maintaining Fluid and Electrolyte Balance
Feeding Tubes
TPN
81
Offer a variety of fluids between meals
Assist residents with drinking
F692: Have beverages available and within reach
Maintaining Evaluate medications that may place a patient at risk for
Fluid and dehydration
Alternate fluids, such as popsicles, gelatin, and ice cream, may
Electrolyte also be offered
Balance For some residents, a fluid restriction may be required to address
conditions, such as edema or congestive heart failure, and may
place them at greater risk for dehydration.
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F 692: Interventions for Unintended
Weight Loss
Interventions related to a resident’s nutritional status must be
individualized to address the specific needs of the resident.
Examples of care plan development considerations can include, but
are not limited to:
Diet Liberalization
Weight Related Interventions
Environmental Factors
Disease Process
Functional Factors
Food Intake
Medications
Maintaining Fluid and Electrolyte Balance
Feeding Tubes
TPN
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F692: Feeding Tubes
Only considered with a resident who is not able
to achieve weight stabilization or other nutrition
interventions have failed
Consult advance directives
Per CMS: Residents with end stage dementia,
use use of a feeding tube does not necessarily
extend life, prevent aspiration PNA , improve
function or limit suffering
See F693 Regulation
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F 692: Interventions for Unintended
Weight Loss
Interventions related to a resident’s nutritional status must be
individualized to address the specific needs of the resident.
Examples of care plan development considerations can include, but
are not limited to:
Diet Liberalization
Weight Related Interventions
Environmental Factors
Disease Process
Functional Factors
Food Intake
Medications
Maintaining Fluid and Electrolyte Balance
Feeding Tubes
TPN
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F692: TPN
This method is used when a resident cannot or should not
eat or drink by mouth
A resident with TPN may require additional monitoring,
such as more frequent weights, to ensure the treatment is
effective.
See F694 Regulation
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F692 Regulation Review:
Nutrition and Hydration Status
• Regulation is divided into sections
• Intent
• Definitions
• Guidance
• Assessment
• Care Planning
• Interventions
• Monitoring
• Investigative Protocol
• Key Elements of Noncompliance
• Deficiency Categorization
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On going monitoring of care planned interventions is expected for
all residents and should include but is not limited to
Interview the resident/and or representative to determine if their
personal goals are met
Direct observation of the resident
F692- Interviews with direct care staff
Monitoring Review resident specific factors identified in nutrition assessment
Are they still relevant?
Have new concerns emerged?
Evaluate the care plan to determine if current interventions are
being implemented and are effective
Meal monitors, weights , labs, nurses notes, MD notes
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F692 Regulation Review:
Nutrition and Hydration Status
• Regulation is divided into sections
• Intent
• Definitions
• Guidance
• Assessment
• Care Planning
• Interventions
• Monitoring
• Investigative Protocol
• Key Elements of Noncompliance
• Deficiency Categorization
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F692-Investigative Protocol
Regulation instructs Surveyors to:
Briefly review the most recent comprehensive
assessments, comprehensive care plan and orders to
determine whether the facility has assessed, identified and
addressed as appropriate, the resident’s nutritional and
hydration needs. This information will guide observations
and interviews to be made in order to corroborate concerns
identified
Always observe for visual cues of psychosocial distress
and harm
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F692 Regulation Review:
Nutrition and Hydration Status
• Regulation is divided into sections
• Intent
• Definitions
• Guidance
• Assessment
• Care Planning
• Interventions
• Monitoring
• Investigative Protocol
• Key Elements of Noncompliance
• Deficiency Categorization
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F692-Elements of Noncompliance
To cite deficient practice at F692, the surveyor's investigation will
generally show that the facility failed to do one or more of the
following:
Accurately and consistently assess a resident’s nutritional
status on admission and as needed thereafter
Identify a resident at nutritional risk and address risk factors
for impaired nutritional status, to the extent possible
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Identify, implement, monitor, and modify interventions (as
appropriate), consistent with the resident’s assessed needs,
choices, preferences, goals, and current professional
standards of practice, to maintain acceptable parameters of
nutritional status
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F692-Elements of Noncompliance
To cite deficient practice at F692, the surveyor's investigation will
generally show that the facility failed to do one or more of the
following:
Notify the physician as appropriate in evaluating and managing causes of the
resident’s nutritional risks and impaired nutritional status
Identify and apply relevant approaches to maintain acceptable parameters of
residents’ nutritional status, including fluids
Provide a therapeutic diet when ordered
Offer sufficient fluid intake to maintain proper hydration and health
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F692-Elements of
This Photo by Unknown Author is licensed under CC BY
Noncompliance
Weight loss, abnormal protein and
electrolyte lab values, and dehydration are
not, by themselves, sufficient to support
noncompliance at F692. Additionally, a
This Photo by Unknown Author is licensed under CC BY-SA
resident does not need to experience
weight loss, abnormal protein levels, D or
dehydration to show noncompliance
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Repeated, systemic failure to assess
F692-Elements and address a resident’s nutritional
of status and to implement pertinent
Noncompliance interventions based on such an
: Severity Level assessment resulted in continued
4 Examples significant or severe weight loss and
functional decline
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F692-Elements of
Noncompliance: Severity Level
4 Examples
Repeated failure to assist a
resident who required assistance
with meals and drink resulted in
or made likely the development
of life-threatening symptom(s),
or the development or
continuation of severely
impaired nutritional status
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F692-Elements Dietary restrictions or downgraded diet
of textures, such as mechanical soft or pureed
Noncompliance textures, were provided by the facility
against the resident’s expressed
: Severity Level preferences and resulted in substantial and
4 Examples ongoing decline in food intake resulting in
significant or severe unplanned weight loss
with accompanying irreversible functional
decline to the point where the resident was
placed on Hospice
97
The failure to provide an ordered
F692-Elements potassium restricted therapeutic
of diet resulted in evidence of
Noncompliance: cardiac dysrhythmias or other
Severity Level 4 changes in medical condition due
to hyperkalemia
Examples
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• The failure to revise and/or implement
the care plan addressing the F692-Elements
resident’s impaired ability to feed of
him/herself resulted in significant, not
severe, unplanned weight change and Noncompliance
impaired wound healing (not : Severity Level
attributable to an underlying medical 3 Examples
condition)
99
F692-Elements of Noncompliance:
Severity Level 3 Examples
• The failure to identify a decrease in
food intake, which resulted in a
significant unintended weight loss
from declining food and fluids, which
resulted in the resident becoming
weakened and unable to participate in
activities of daily living
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The failure to assess the relative risks and
benefits of restricting or downgrading F692-Elements
diet and food consistency or to
accommodate a resident’s choice to
of
accept the related risk resulted in Noncompliance
declining food/fluid intake and significant : Severity Level
weight loss 3 Examples
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F692-Elements of Noncompliance:
Severity Level 3 Examples
The failure to accommodate documented resident
food dislikes and preferences resulted in poor
food/fluid intake and a decline in function
The failure to provide a gluten-free diet (one free of
wheat, barley, and rye products) as ordered for a
resident with known celiac disease (damage to the
small intestine related to gluten allergy) resulted in
the resident developing persistent gastrointestinal
symptoms including significant, not severe, weight
loss, chronic diarrhea, and occasional vomiting
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Failure to obtain accurate weight(s) and to verify
weight(s) as needed
Failure to provide a prescribed sodium-restricted
F692-Elements therapeutic diet (unless declined by the resident
of or the resident’s representative or not followed by
the resident); however, the resident did not
Noncompliance experience medical complications such as heart
: Severity Level failure related to sodium excess.
2 Examples
103
F692-Elements of Noncompliance:
Severity Level 2 Examples
Failure to provide additional nourishment
when ordered for a resident, however,
the resident did not experience
significant or severe weight loss
The facility’s intermittent failure to
provide required assistance with eating
resulted in poor intake, however, the
resident met identified weight goals
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F692-Elements of Noncompliance: Severity Level 1
Example
Severity Level 1: No Actual Harm with Potential for Minimal Harm
The failure of the facility to provide appropriate care and services to maintain
acceptable parameters of nutritional status, which includes hydration, and
minimize negative outcomes places residents at risk for more than minimal harm.
Therefore, Severity Level 1 does not apply for this regulatory requirement
105
Applying it to Practice:
Tips for Preventing
Unintended Weight Loss
Establish and follow policy and
procedure for obtaining weights
Focus on resident centered
approach
Frequent monitoring of weight
and meal intakes
Auditing of meals to ensure food
is palatable
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Open communication with IDT
team
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Case Study 12. Your facility has identified that Phyllis had
significant unintended weight loss. What do you do
Questions now?
107
My resident has potential
unintended weight loss, what now?
Ensure Accuracy of weight
Reweigh your patient per facility policy
Weight errors are common
If weight loss is found to be accurate, refer significant
weight changes to Physician, RDN or Designee and
Patient/Responsible party ASAP
Have set procedure with designated employees in
place for timely notification
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My resident has unintended
weight loss, what now?
RDN to assess/reassess patient and
document
Determine underlying root
causes for weight loss
Start Interventions based on identified
root cause of weight loss
Individualize interventions to
address resident’s specific needs
and preferences
Update Care Plan
Add to high risk IDT meeting for more This Photo by Unknown Author is licensed under CC BY
frequent monitoring and follow up
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Case Study Review
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111
References
Danilovich MK, Norrick CR, Hill KC, Conroy DE. Nursing Home Resident Weight Loss During Coronavirus Disease 2019
Restrictions. J Am Med Dir Assoc. 2020;21(11):1568-1569. doi:10.1016/j.jamda.2020.08.032
Dorner B, Friedrich EK. Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older
Adults: Long-Term Care, Post-Acute Care, and Other Settings. J Acad Nutr Diet. 2018 Apr;118(4):724-735. doi:
10.1016/j.jand.2018.01.022. PMID: 29576092.
Gaddey HL, Holder K. Unintentional weight loss in older adults. Am Fam Physician. 2014 May 1;89(9):718-22. PMID: 24784334.
Gallagher-Allred C, Robinson G. Unintended Weight Loss in Older Adults: ADA Evidence- Based Practice Guidelines.
Connections. https://higherlogicdownload.s3.amazonaws.com/THEACADEMY/4556f4af-bcea-4fd9-8fc9-
5647e0d15658/UploadedImages/DHCC/Documents_/UWL.pdf. Published November 2011. Accessed June 24, 2021.
Niedert KC, Carlson MP. Nutrition Care of the Older Adult: a Handbook for Nutrition throughout the Continuum of Care. Chicago:
Academy of Nutrition and Dietetics; 2020.
Renaud M, Thibault C, Le Normand F, et al. Clinical Outcomes for Patients With Anosmia 1 Year After COVID-19
Diagnosis. JAMA Netw Open. 2021;4(6):e2115352. doi:10.1001/jamanetworkopen.2021.15352
Stajkovic S, Aitken EM, Holroyd-Leduc J. Unintentional weight loss in older adults [published correction appears in CMAJ. 2011
May 17;183(8):935]. CMAJ. 2011;183(4):443-449. doi:10.1503/cmaj.101471
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