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Promising Practices in Dining

Examining the Institutional Dining Experience

While each nursing home possesses a unique culture and set of dining-related issues, the common nursing home dining experience seems to be intricately tied to the structure of systems that typically accommodate multiple dietary regulations and operational efficiencies.  Nursing homes have established multi-disciplinary systems which intersect with a complex dining process.  Over time the nursing home dining experience has become institutionalized, and in many instances dining is not a pleasurable experience for residents.  The release of the June 12 2009 CMS Interpretive Guidelines reinforces the need for nursing homes to re-evaluate resident quality of life, including the methods by which providers honor resident dignity and choice in dining. By examining the complexity of the dietary and dining process, it is possible to understand how and why nursing homes became institutionalized.







The Resident is always at the core of multiple processes that affect the resident.

The Clinical Assessment and Interdisciplinary Resident Care Planning Process

Before a resident meal can even be served, a clinical team (interdisciplinary care plan team) must properly assess each resident for food and dietary related risks, preferences, and then identify and  order the correct diet.  A number of indirect and direct care givers may provide input into this resident care planning process including but not limited to:  the resident him/her self, the resident's legal decision-maker, and a host of team members such as a registered dietician, physician, speech or occupational or physical therapist, nursing assistant and dietary aide.  At the center of this care planning process is the goal of correctly assessing the resident's clinical needs and food preferences upon admission and throughout his/her stay in the nursing home.

The following is an excerpt from Linda Bump's, "The Deep Seated Issue of Choice" from the 2010 Creating Home in the Nursing Home II: A National Online Symposium on Culture Change and the Food and Dining Requirements. Bump reflects how the institutional care planning process does not maximize the fundamental right of the resident to have control over the dining experience.

"OBRA 87 gives us the opportunity and obligation to reexamine our attitudes, our routines, and personal assumptions regarding resident rights. We have the chance to re-focus our efforts and in the process, social awareness and ethical practices that emphasize individuality will evolve. When we reaffirm the dignity of each resident, we will also enrich the lives and values of our staff members. And, as we seek new ways of enhancing independence and offering new choices and opportunities to our residents, staff members will feel rewarded by those they empower. Enriched lives means more productive lives for our staff. ride and personal determination will improve the quality of life for our elders. Busy care-givers are routinely required to make "on the spot" decisions. In the past, these decisions may have been made with the primary focus on efficiency and not on thoughtful consideration to individuality. To place appropriate emphasis on resident rights, we may need to sacrifice some efficiency for the sake of human pride. Goals must be set that hold individual dignity in higher esteem than overall facility efficiency. It will not be easy. Years of caring practices and habits." (Bump 2010)
Click here to download the paper and view the entire webinar and background paper.

Resident choice in dining time is not a regulatory requirement.

F242 CMS Interpretive Guidelines

An interdisciplinary team continuously must identify and update relevant resident needs and preferences, and constantly review new clinical and observational data intended to achieve the best outcome for each resident while minimizing resident risks. Significant attention is given to the "non-compliant resident" (e.g., the resident diagnosed with diabetes who likes and eats sugary foods whenever he/she wishes in spite of the fact that this may negatively affect his/her health), and to the clinical accuracy of each resident assessment (e.g., history and physical, weights, therapeutic diets). Assuming that a resident's medical record is accurate, and that the correct diet has been prescribed, the process of meal preparation and meal service concurrently begins.


Institutional Food Preparation Process
Traditionally, it is typically the dietary department's responsibility to receive resident diet orders and then create diet cards, diet indexes, meal tickets and/or enter new information into a host of computer and/or paper-based resident diet recognition systems, which are directly linked to meal preparation and eventually to food ordering and inventory management. In a central kitchen, where most meals are traditionally prepared, the dietary staff must comply with a host of regulations. At the top of the compliance list are infection control and food handling requirements, food temperature and Hazard Analysis and Critical Control Points (HACCP) controls, food storage, and general environmental sanitation, to name a few. The desire to maintain strict control over meal production often links to the desire to ensure that only trained dietary staff control the food preparation process. As the meal is prepared, a series of dietary staff are engaged in various aspects of food preparation, all who have presumably been trained in many of the regulations mentioned above.

As the meal is prepared, a series of dietary staff are engaged in various aspects of food preparation, all who have presumably been trained in many of the regulations mentioned above. Traditionally, a cook may prepare several entrees and alternatives in accordance with a planned menu and any therapeutic diets that must be served. As food is prepared, it is typically maintained in a steam table where the plating of food on resident meal trays begins. One person may plate the food while another double checks that the plated items match the correct resident and diet (e.g., condiments, silverware, special likes and dislikes) and then covers the plated food to keep it hot. The entire meal, which has been plated on a meal tray, is then slipped into meal carts or other meal delivery systems designed to hold food temperatures. At this point, the meals are "transported" to various locations where residents will be served. Some nursing homes even use an overhead paging system to announce "Trays are up!" just to make sure that designated staff rush from ever corner of the nursing home to assist with the dining process.


The Meal Delivery Process
Once meals carts and trucks are delivered to the various resident dining locations, nursing care givers are usually assigned to serve the meals to each resident.  Since most meal trays are typically organized by resident room or wing or by residents who eat in a particular location, nursing staff can quickly remove meal trays from tray trucks and serve them to residents efficiently. Typically, at all meals, staff scramble to ensure residents are "ready" for meals. This may include the practice of awakening residents who are sleeping, interrupting resident activities, or otherwise imposing a rigid dining schedule. Residents are "transported" to and from  various locations in order to eat.  In some instances residents may choose to remain in their rooms to eat meals and in others they may be required to eat in a particular location.

Widespread meal tray use has been a huge part of the mainstream institutional nursing home environment, in the same fashion as other institutional environments such as hospitals, schools and prisons.  Some providers have attempted to accommodate resident dignity and special diets by decorating meal trays with fancy tray liners (e.g., a red tray liner to indicate a person who has diabetes).  The use of meal trays has proven to be especially efficient in serving residents who choose to eat or need to eat in their rooms. Some nursing homes place the meal tray on a resident's over bed table in their room, or use meal trays in a centralized dining room, and then remove the trays at the end of the meal service.

Regardless of their use, the CMS Interpretive Guidance F - 252 Safe, Clean, Comfortable and Homelike Environment requires homes to strive towards the elimination of meal trays.


The Dining Experience
Many residents find the dining experience to be undignified, sterile, and part of a daily task that must be accomplished. Residents who require assistance with meals are often provided with assistance based upon the residents need and both the ability and availability of a trained staff member to assist them. Some require only partial assistance such as ensuring that the resident's meal is within reach of the resident and that all the resident's needed utensils are present. In other cases a resident may require complete assistance with everything with pre-meal and post-meal grooming and the entire process of eating. In an institutional setting staff members are essentially assigned to residents to ensure adequate meal supervision and assistance. Often staff refer to these residents as "feeders," and in an institutional setting staff may even maintain "feeder" lists, an institutional label that CMS has identified in its release of Interpretive Guidance changes F-241 (Dignity)

The "clothing protector" (thought to be a more adult, dignified term than "bib") experience also has institutional roots as it was originally designed to protect and promote resident dignity. Many providers simply routinely apply a clothing protector to each resident at all meals. It has been a method used to preserve a resident's appearance and dignity by preventing food spills on his/her clothing. Regardless of the name, the use of a clothing protector (aka "bib") has also been identified in the CMS Guidance as an undignified practice in the release of the Interpretive Guidance F - 241 Dignity

The following is an excerpt from Carmen Bowman's paper, "The Food and Dining Side of the Culture Change Movement: Identifying Barriers and Potential Solutions to furthering innovation in Nursing Homes." from the 2010 Creating Home in the Nursing Home II: A National Online Symposium on Culture Change and the Food and Dining Requirements.

"As part of a dignified dining experience, forward-thinking pioneers questioned, and then simply stopped using bibs, serving food on trays, and got rid of what used to be called "feeder tables" -- tables designed in a horseshoe shape in order to feed four residents at a time. What is also becoming a former long term care practice is referring to those needing assistance or to be fed as "feeders." Harm was not meant by these ideas, but they have contributed to putting the task, and the goal of efficiency before the person. Many have replaced the language "feed," "fed," and "feeder" with "dining," "dine," "assist with dining," and even more personal, some encourage the normal practice of using the person's name instead of any sort of label."(Bowman, 2010)

Learn more about barriers and solutions to improving the resident dining experience. 
Click here to download the paper and view the webinar.
Staff should not eat meals with residents.

Pg. 14, 34 and 35 Dining Symposium Background Paper


Some institutional settings have not yet accommodated basic resident needs during meal times and may have a number of staff who do not fully engage with residents during a meal. Some staff may be speaking with each other rather than focusing solely on the resident and his or her needs during the meal. Additionally, some staff may also not be attuned to resident needs, such as the possibility that a resident may need to use a restroom before, during or after a meal. CMS, in its Interpretive Guidance F - 241 Dignity has identified these practices as undignified.

In short, the institutional nursing home meal experience has been all about a structured meal process which has been established to help providers deliver meals efficiently and to comply with existing regulations, but these regulations were not intended to limit resident choices or to reduce resident dignity. In an institutional setting residents are typically offered three meals per day at planned times, and some form of a substantial evening snack. Meal times are posted, rather rigidly enforced, and resident choices over meal and meal time are extremely limited based upon the resident's diet and alternate foods available at any particular meal service. With the release of CMS Interpretive Guidance F - 242 Self-Determination and Participation providers are required to honor residents choices over their schedule, including what time they wish to eat, as well as the presumption that their meal preferences will also be honored.

The following is an excerpt from Linda Bump's, "The Deep Seated Issue of Choice" from the 2010 Creating Home in the Nursing Home II: A National Online Symposium on Culture Change and the Food and Dining Requirements. It reflects how the institutional dining process does not maximize a resident's ability to have control over the dining experience.

"Traditionally we define choice in our dining services as the opportunity to express our likes and dislikes during an admission interview, or to circle a menu one day, or week, or month in advance. We may also define choice by the presence of the steam table in the dining room, but it quickly becomes token choice with the use of computerized tray ticket systems which control the food served from the steam table to a specific resident. What could be worse than seeing and smelling a tempting food, only to be served a different food specified on the ticket laying on the pre-set table -- resident autonomy at this particular meal is overridden with preferences stated during an assessment process or a therapeutic diet extension. And sadly, acknowledge to yourself how often the dining and nursing staff expresses their frustration with impossible-to-please residents who select something they have previously asked us not to serve them. Consider the control you personally exercise daily in dining choices, and the pleasure that control brings to you each day with food." (Bump 2010)
 Learn more about resident choice and dining
Click here to download the paper and view the entire webinar and background paper

Nursing homes cannot change their dining times to meet individual resident needs because of the existing '14-hour and 16' rules."

TO SEE HOW RESIDENT RIGHTS ARE NOT TO BE DIMINISHED BY THE 14 AND 16 HOUR RULES visit Pg. 29 of the Dining Symposium Background Paper


While some nursing homes have already made great strides towards improving the residents' dining experience, all nursing homes will be required by CMS to revisit dining practices. Fortunately, at the same time that dining practices are changing, providers and regulators are working together to help create an atmosphere where regulations and survey are not necessarily in the way of innovation. CMS and Pioneer Network recently collaborated on Creating Home in the Nursing Home II: A National Symposium on Culture Change and the Food and Dining Requirements. The online Symposium includes a downloadable background paper and a series of webinars, including papers authored by webinar presenters that can also be downloaded. An in-person invitational stakeholders workshop was also convened by CMS and Pioneer Network on May 14, 2010 to review the presenters' recommendations and add recommendations that will be used to further understanding of the food and dining side of the culture change movement and to identify solutions to furthering innovation in nursing homes.

As American citizens, we fight for our inalienable rights and most of us do not have an institutional hierarchy at the helm of our care. In a nursing home, resident "rights" are also sometimes perceived to conflict with a nursing home's fundamental need to protect resident safety. It can be difficult for providers to know how to balance resident autonomy and control over daily life while also meeting a multitude of regulations. At the center of the balancing act is the dining experience. Resident rights over food choices and meal schedules are beginning to be reinforced in regulatory guidance, as is examined in the quote below.

The following is an excerpt from Linda Handy, MS, RD, "Survey Interpretation of Regulations" from the 2010 Creating Home in the Nursing Home II: A National Online Symposium on Culture Change and the Food and Dining Requirements. It demonstrates how resident preferences must be considered as well as the resident's clinical condition.

"A very important change in the wording and intent addressing resident rights occurred with the revision of F 325 Surveyor Interpretive Guidance, implemented 9/1/08. This regulatory intent was changed to emphasis, as part of the assessment, not only the need but also the RESIDENT'S PREFERENCE. The new intent stated: "Provides a therapeutic diet that takes into account the resident's clinical condition, and preferences, when there is a nutritional indication."

This is the abstract of ADA's position: "It is the position of the American Dietetic Association (ADA) that the quality of life and nutritional status of older residents in long-term care facilities may be enhanced by liberalization of the diet prescription. In 2003, ADA designated aging as its second 'emerging' area. Nutrition care in long-term settings must meet two goals: maintenance of health and promotion of quality of life. The Nutrition Care Process includes assessment of nutritional status through development of an individualized nutrition intervention plan. Medical nutrition therapy must balance medical needs and individual desires and maintain quality of life. The recent paradigm shift from restrictive institutions to vibrant communities for older adults requires dietetics professionals to be open-minded when assessing risks versus benefits of therapeutic diets, especially for frail older adults. Food is an essential component of quality of life; an unacceptable or unpalatable diet can lead to poor food and fluid intake, resulting in weight loss and under nutrition and a spiral of negative health effects. Facilities are adopting new attitudes toward providing care. 'Person-centered' or 'resident-centered care' involves residents in decisions about schedules, menus, and dining locations. Allowing residents to participate in diet-related decisions can provide nutrient needs, allow alterations contingent on medical conditions, and simultaneously increase the desire to eat and enjoyment of food, thus decreasing the risks of weight loss, under nutrition, and other potential negative effects of poor nutrition and hydration."
(Handy, 2010)

Learn more about the balance between resident choice and regulations.
Click here to download the paper and view the entire webinar and background paper.

Cost of changing my dietary culture will always be prohibitive.

Pg. 17-18
Dining Symposium Background Paper

Providers are increasingly experimenting with strategies to advance their dining practices to be more dignified, pleasurable experiences and to comply with the new June 12 2009 CMS Interpretive Guidelines.  

As part of our Creating Home: Promising Practices in Dining Series, we will explore ways that providers are changing their dining practices so that it is a more dignified, pleasurable experience, an intended outcome of the quality of life interpretive guidelines.


Would You Like to Share Your Promising Practices in Dining and Learn From Others
We encourage providers to share their practices, operational tools and resources, including vendors that have products and services that have helped homes to meet regulatory expectations at the lowest possible cost that you have implemented to enhance the dining experience.


Submit a promising practice by visiting our Promising Practices Link

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