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Unintentional weight loss

A very common adverse clinical outcome for residents is unintentional weight loss. It can contribute to a decline in general health, energy, about to heal in relation to skin / wound care and increase the risk of accidents.

Ensuring adequate nutritional intake relevant to the health status for each resident is ultimately the responsibility of Registered Nurses. There has been the perception in some instances that it’s normal to lose weight as people age. While there is an increased tendency to lose weight, it should not be considered normal.

If unintentional weight loss is detected, ensure thorough multi-disciplinary clinical assessment and development of specific short term care plan to define strategies to meet the specified care plan goal. Offering more frequent high energy (high calorie) and high protein snacks and drinks between main meals and instigating the recording of all food and fluid intake should be part of this plan (unless contraindicated). The dietitian can best help guide you through the best nutritional support for each individual resident and their circumstances at the time.

Unintentional weight loss or the undesirable decline in total body weight over a specified period of time is common however should not be ignored as ‘part of ageing’.  Sarcopenia (muscle loss in the elderly) is also common however not inevitable and should be addressed through a targeted exercise and balance programme. Light body weight in the elderly have been shown to have a detrimental effect on the resident ability to function and on their general quality of life.

Unintentional weight loss of 3 -5 percent (or greater) in 30 days (or 10 percent in 180 days) must be monitored more closely and a short term care plan must be developed to promote weight loss cessation and implementation of weight management practices. RN’s must ensure they review regular weight monitoring records to identify progressive changes and respond to adverse patterns.

Residents that have been determined to be in later stages of palliative care or receiving terminal cares should be excluded from the need for close monitoring and related care planning related to trying to reverse unintentional weight loss.  This is at the discretion of the Registered Nurse in consultation with the Doctor and next-of-kin / advocate / whanau.  Discussions will also be had with the resident and the Medical Practitioner regarding the extent or type of tests, investigations and interventions that are desirable.  These must be clearly documented in the Care plan evaluation and interventions recorded in the long term care plan and Doctors consultation notes.

Ensure the specific instructions (interventions) are recorded in the care plan for staff to implement on a consistent basis.  Ensure these are reviewed at each weight monitoring event (time-frame specified in care plan) and adjust interventions according to weight monitoring outcomes.

If after two weeks of weekly monitoring the weight has not stabilized or started to increase, consult a Dietitian to review the resident and provide recommendations.  Ensure any recommendations are followed as directed.

Treat any underlying cause and continue monitoring of weight until it has reached optimum levels in accordance with care plan goals.  Return to monthly monitoring of weight at this stage.  Those on special diets must be monitored more closely than those residents that are independent with eating and drinking or those that have no identified difficulties which may lead to increased potential for unintentional weight loss.

Case Study:

An 84 year old female resident (Mrs A) with a diagnosis of chronic heart failure and early dementia was noted to be experiencing progressive weight loss. Staff indicated she was able to physically feed herself but often refused to eat, pushing the meal tray away from her.  She was able to express her needs to the extent of saying she didn’t want her meal. Staff recorded this in the progress notes however no investigation was done to identify the cause of her refusal to eat. Her weight had reduced at that point to 38kg having had an admission weight of 48kg only six months previously. Staff noted Mrs A was often sleepy during the day and expressed their belief her dementia was advancing. A new Clinical Nurse Lead (CNL) sat down and talked with Mrs A to discover that her mouth wasn’t sore and her dentures were well fitting. There appeared to be no difficulty with her ability to eat or swallow.  The CNL consulted with the dietitian to support the assessment process. It was decided that a staff member would sit with Mrs A and gently talk with her as the staff member offered small spoonfuls of food.  Mrs A obliged with eating with no resistance or protest and seemed to enjoy her meal. Progressively day after day her intake increased and she seemed to be sleeping less. She had more energy and within a period of one week had shown an 800 gram weight gain.  Staff continued with supporting Mrs A with assisting her with her meal and within 6 weeks her weight had increased from 38kg to 41kg.  At that time she was no longer sleeping most of the day and had resumed feeding herself. Short term care plans were instigated at the start of this process and more detailed long term care planning and regular assessment was also documented. Family input had been sought to gain a greater understanding of Mrs A’s previous eating patterns and she was able to talk about the foods she enjoyed having with her family.  Asking questions about a context such as family meals assisted the staff in gaining more information than if they’d simply asked Mrs A what her favourite foods were.  Giving a direct answer to a specific question wasn’t easy for Mrs A however she was able to talk about family meal times which proved a valuable source of information for nursing staff in supporting her. At the end of an 8 week period Mrs A had more energy, was interacting more with others, was sleeping less during the day,appeared happier and was enjoying her meals. She was no longer refusing to eat.  It stands to reason that when a person is lacking nutrients, they may actually lose the energy needed to feed themselves.  Getting the basics right is a good place to start.

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Audit Tips – Common findings in audits

Audits in the aged residential care sector in New Zealand are assessed against their ability to comply with a raft of legislation, standards and contractual requirements.

Below are common findings which continue to be reported on during audits:

 
CriteriaGaps in meeting full compliance
Consumer Rights- 1.1·         Complaints management processes not completed as per                   requirements. Eg; not being logged on the complaints                         register, time-frames not being met, lack of evidence of                     resolution.
Organisational Management– 1.2·         Not completing internal audits·         Not evidencing completion of regular meetings·         Corrective action plans not being developed or completed·         Lack evidence of investigation·         Lack evidence of family notifications of adverse events·         Lack evidence of reference checks at time of employing new             staff·         Lack of 1st Aid certified staff member on each duty in each                 work area – this must consider the size, and layout of your                   building.·         No signed employment agreement or job description·         Lack evidence of timely completion of orientation·         Annual appraisals not completed for all staff
Service Delivery– 1.3·         Lack of timely clinical assessment·         Lack of assessment and care-planning related to behaviours               of concern (challenging behaviours)·         Lack of evidence in progress notes of Registered Nurse input·         Lack of evidence in progress notes of interventions from long             term care plan·         Lack of evidence of family / residents input·         Lack of evidence of outcomes from clinical assessments                     (including InterRai) being used to inform the care plan·         Transcribing of medications in care plans·         Doctor’s instructions in medical notes not followed /                             implemented·         Wound assessment chart not updated as per wound care plan·         Neurological observations not completed following falls                      where there was a possibility of the resident having sustained             a head injury·         GP reviews not recorded at time-frames determined in ARRC·         Lack of evidence of RN acting on caregivers reporting of                     adverse health symptoms in progress notes.
Safe and Appropriate Environment– 1.4·         Lack of evidence of medical calibration of equipment·         Hoists not checked and verified as fit for use.·         Surfaces unable to be cleaned adequately·         Non labelled or decanted chemicals·         Lack of evidence of hot water temperatures not exceeding 45            degrees 
Restraint minimisation and safe practice – 2.0·         No evidence of enabler monitoring·         Lack of evidence of incomplete restraint register.
Infection prevention and control– 3.0·         Infection control nurse in care facilities who have not                           completed training in infection prevention and control and                  therefore cannot demonstrate relevant knowledge on which              to base practice and monitor staff performance.·         Not all infections are noted on the infection register. Your                    policy and procedure should include the internationally                      recognised definitions for infections on which to base your                  monitoring.  For those of you using the HCSL policies and                   procedures, these definitions are noted within the Anti-                     microbial  Policy – document code IC1. 

Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of your service.

For more assistance with this contact us.

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Medication Management Audit Tips

 

Medication management relates to section 1.3.12 of the Health and Disability Services Standards and referred to in section D5.4 of the ARRC.  There are key reference documents which provide reference at facility level which should be used in conjunction and addition to your organisation policies and procedures.  These reference documents are (first two are key for residential care):

Medication errors of any type, when reporting through the audit process to MoH HealthCert as part of your audit, will receive a higher ‘weighting’ than other partial or non-attainments.  Even a single signature missing off an administration signing sheet may come into this category and mean your audit outcome is diminished.  Below are common errors which continue to be made:

Aspect of medication management Common Errors 
Medication chartsNot datedNot signed by the prescriberNot signed by the General Practitioner or Nurse Practitioner at each review (3 monthly)Not legibleAllergies not documented (or inconsistent with other resident documents)Transcribing on medication charts or PRN signing sheetsPRN medication charting does not include ‘indication for use’Medication order does not include time, dose, frequency, route, type etc
Signing sheetsMissed signatures on the signing sheetsOnly one signature (instead of two) on controlled drug administration records and registerPRN medication not signed for accurately
Self-medicating residentsCompetency to verify self-medication not signed by prescriberCompetency for self-medication not signed as having been reviewed by prescriber (3 monthly)Staff verification of self-medicating occurred not recorded on a shift by shift basis (as relevant to the individual residents medication order)Not retaining a current list of all medication ordered for self-medicating residents
StorageMedication not securely stored (also see ARRC D15.3(c) Controlled drugs not entered accurately into Controlled Drug Register (at time of supply or return to pharmacy)Controlled drugs not stored in locked cabinet in locked roomDrug trolley left in common areas unlockedExpired medication continue to be stored on site (should be returned to pharmacy)Medication for resident who has been discharge or deceased remain on siteMedication fridge temperature not monitored / recordedLabels on medication containers not clear / legible
Identification of residentPhotograph not representative of current presentation of resident (photograph should be colour)Photograph of residents not validated regularly
Medication errorsNot reportedNot managed (through an adverse event management process to ensure identification of contributing factor and preventive measures).
CompetencyAll staff (including Registered Nurses and Enrolled Nurses) involved in medication administration must have first successfully completed a medication competencyAnnual review of medication competencies

If you’re uncertain about the competency of a particular staff member, do not be tempted to sign them off and monitor.  The risk is too high for the residents and your organisation.  Medication errors can be classified as ‘sub-standard care’ and due to the possible consequences, are at least a moderate risk.

Remember when changing staff around, the key priority is do you have a medication competent staff member on each duty and if controlled drugs are being administered, you need a minimum of two medication competent staff rostered on each duty.  Registered Nurses cannot be leaving the ‘hospital’ area of the facility to administer medication in other areas as this leaves the hospital residents vulnerable so this also needs to be factored into your rostering.  Refer to the Aged Related Residential Care Contract (ARRC) for further information.

Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of medication management.

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Health and Safety at Work 2015 implications for Aged care and Retirement Villages

I’ve been working through the new Health and Safety at Work 2015 legislation and have concerns about how this applies to not only care facilities and new reporting requirements, but also to Villages.  This legislation could cause all sorts of issues for you and in my view needs further clarification as to how it is to be applied to ARRC residential care setting and Villages that come under the RVA.

The Retirement Villages Association define a ‘Licence to Occupy’ as –

“Licence to occupy – This is the most common form of occupation right in New Zealand. A licence to occupy gives you the right to live in your residential unit and to use to village facilities according to the terms of the licence to occupy. The ownership of the land and building remain with the village operator.”

The new Health and Safety at Work Act 2015 which applies from the 4th of April 2016 requires a PCBU (Person Conducting a Business or Undertaking) to report notifiable injuries or illnesses and all notifiable incidents. Looking closer at the terminology used in the legislation is states in relation to responsibility to notify –

Health and Safety at Work Act 2015.
Sub Section part 2 – clause 37 Duty of PCBU who manages or controls workplace  (this appears to apply to Village operators as well as ARRC providers)

(4) In this section, a PCBU who manages or controls a workplace—

(a) means a PCBU to the extent that the business or undertaking involves the management or control (in whole or in part) of the workplace; but
(b) does not include—
(i) the occupier of a residence, unless the residence is occupied for the purposes of, or as part of, the conduct of a business or undertaking.

The red text seems to be the rationale for notifications being required from care facilities but it would seem it also applies to village units, studios and apartments.  How are you going to know if your village residents have had an injury or illness which is classified as notifiable?

Part 1 Section 23 –  Meaning of notifiable injury or illness –

(1) In this Act, unless the context otherwise requires, a notifiable injury or illness, in relation to a person, means—
(a) any of the following injuries or illnesses that require the person to have immediate treatment (other than first aid):

(i) the amputation of any part of his or her body:
(ii) a serious head injury: (This could apply in the case of a fall where a resident has a knock to their head?)
(iii) a serious eye injury:
(iv) a serious burn:
(v) the separation of his or her skin from an underlying tissue (such as
degloving or scalping): (Does this apply to skin tears of a particular size?)
(vi) a spinal injury:
(vii) the loss of a bodily function:  (Fall resulting in fracture?)
(viii) serious lacerations:

(b) an injury or illness that requires, or would usually require, the person to be admitted to a hospital for immediate treatment:
(c) an injury or illness that requires, or would usually require, the person to have medical treatment within 48 hours of exposure to a substance:

Implementing this into this sector may be difficult due to the rights to privacy of those living in ‘independent’ ORA situations. The key definer in this section is clause a) any of the following injuries or illnesses that require the person to have immediate treatment (other than first aid).  If an ambulance is called to attend to a village resident this could be deemed ‘immediate treatment’.

Part 1 Section 24 – Meaning of notifiable incident –

(1) In this Act, unless the context otherwise requires, a notifiable incident means an unplanned or uncontrolled incident in relation to a workplace that exposes a
worker or any other person to a serious risk to that person’s health or safety arising from an immediate or imminent exposure to—

(a) an escape, a spillage, or a leakage of a substance; or
(b) an implosion, explosion, or fire; or
(c) an escape of gas or steam; or
(d) an escape of a pressurised substance; or
(e) an electric shock; or
(f) the fall or release from a height of any plant, substance, or thing; or
(g) the collapse, overturning, failure, or malfunction of, or damage to, any
plant that is required to be authorised for use in accordance with regulations;
or
(h) the collapse or partial collapse of a structure; or
(i) the collapse or failure of an excavation or any shoring supporting an excavation;
or
(j) the inrush of water, mud, or gas in workings in an underground excavation or tunnel; or
(k) the interruption of the main system of ventilation in an underground excavation or tunnel; or
(l) a collision between 2 vessels, a vessel capsize, or the inrush of water into a vessel; or
(m) any other incident declared by regulations to be a notifiable incident for the purposes of this section.

Clearly the majority of these apply to manufacturing and industrial sites however some could potentially be applied to the care and village setting.

What do you see as your liabilities?  What is the responsibility for the operator in managing potential risk?  Which assessment tools and accompanying definitions are we best to apply if any?  If alcohol consumption by a resident or failing cognitive state is likely to contribute to their safety, where are the boundaries for responsibility between the resident and the operator? 

Share your comments ….

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Multidrug resistant organisms

Multidrug resistant organisms – an update for residential care

The increase in bacteria that are resistant to antibiotics is now a major concern for healthcare providers across the world. Recently the UK’s top doctor, Dame Sally Davies, described antibiotic resistance as ‘serious a threat as terrorism’, predicting that people may die from routine post operative infections within 20 years as there would be no effective antibiotics available.

Multidrug resistant organisms (MDRO or MRO) are organisms that are resistant to several antibiotics to which they would normally be susceptible or two or more classes of antibiotics1. This means that the choice of antibiotics to treat an infection with an MDRO is usually not the first one and may have limited effect.

The MDRO that are most commonly encountered in residential care are MRSA (methicillin resistant Staphylococcus aureus) and extended-spectrum β-lactamase (ESBL) producing organisms. However there are some new kids on the block, which, although seen more in the acute healthcare sector, are finding their way into our residential care facilities. These very resistant superbugs include Vancomycin resistant enterococci (VRE) and Carbapenem resistant enterobacteraciae (CRE).

Some of the characteristics of these MDRO are summarised in the table below

Summary of MDRO characteristics

MDRONormal habitatInfectionsMode of transmission
MRSASkin (nares, groin)Skin, urinary tract, chest, woundContact – colonised or infected skin/ulcerContaminated items/surfaces
ESBLsBowelUrinary tract, wound, pneumoniaContact with faecal or urine contaminated items. Contact with colonised wound/ulcer
VREBowelUrinary tract, wound, pneumoniaContact as for ESBLsContaminated environment
CREBowelUrinary tract, wound, pneumoniaContact as for ESBLs 

High prevalence rates of MDRO colonisation in long term and aged residential care facilities are frequently reported in the literature. Although MDRO are often introduced into a facility from a resident who has recently been in hospital or has had multiple courses of antibiotics, they can spread easily through ARC. This may be due to poor infection prevention and control (IPC) practices, poor facility design or inadequate number of toilets or merely through social contact between residents. However despite the high rates of MDRO in residential care, it does not appear that residents are at greater risk of infection with these organisms.

Residential care facilities can play their part in helping to reduce the spread of MDRO by having an effective infection prevention and control programme which includes the following specific to MDRO:

  • the use of standard IPC precautions and adherence to good hand hygiene practices
  • Additional IPC measures when indicated
  • surveillance of infections
  • antimicrobial stewardship e.g. reducing inappropriate use of antibiotics for asymptomatic bacteriuria.
  • Informing the emergency department or ward of the resident’s MDRO colonisation if admitted to hospital. This is important because additional precautions may be necessary in the acute hospital setting.

The care of a resident with an MDRO in an ARC facility must reach a balance of the needs of the resident to live a normal life within their ‘home’ and the responsibility to the wider society to prevent further transmission of the MDRO, which contributes to the increase in antibiotic resistance.

Staff and colonised or infected residents should understand the methods of spread of the MDRO and use suitable precautions to break this chain of infection transmission. In many cases this will be the use of routine standard precautions, particularly hand hygiene.

A risk assessment for each resident should be undertaken and the precautions tailored to their risk factors for spread. For example, emptying and handling urinary catheters and bags increases the risk of spread of ESBLs and apron and gloves should always be worn for this task.

Most MDRO colonise the bowel so faecal incontinence is always a risk factor for transmission.

For some of the more resistant organisms such as VRE and CRE, it is advisable that the colonised resident has their own room and toilet facilities and that staff wear a gown/apron and gloves for all cares that involve direct contact with wounds, emptying catheter bags, toileting or other intimate cares.

By ensuring staff are informed, regularly use standard precautions and good hand hygiene practices and implement antibiotic stewardship, together we can help reduce the rate of increase in MDRO in our society.

  1. Ministry of Health. 2007. Guidelines for the Control of Multidrug-resistant Organisms in New Zealand. Wellington: Ministry of Health

Ruth Barratt RN, BSc, MAdvPrac (Hons)

Independent Infection Prevention & Control Advisor

Infectprevent@gmail.com

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