In this LTC case study, we look at a real life patient with wounds. Start thinking about the MNT in part 1 and then move to part 2 to write the note.
LTC Case Study Part 1 - The MNT
LTC Case Study Part 1
This is part one of a short case study review of a patient in long-term care. It’s close to what you might see happening to a real-life patient when working in a LTC or even sub-acute facility.
In this post we’ll look at your patient and their clinical needs. In part 2, we’ll review how to write their note and choose their PES statement.
Let’s start by meeting our patient.
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LTC Case Study - Start Here: Meet Your Patient
Last night, your 83 year old patient Mr. Jute was readmitted to the long-term care facility where you work. He had been discharged to the local hospital almost 4 weeks ago for a possible UTI and some SOB.
Mr. Jute has been a resident of this facility for the past year and you’ve gotten to know him well. He was first admitted after his previous R-hip and then R-knee surgeries resulted in chronic pain and poor mobility. He has an additional PMH of HTN, coronary artery disease (CAD), osteoarthritis, and depression. Over the last six months, you’ve also been treating him for one stage 4 and three stage 2 pressure injuries.
With Mr. Jute out of your care for longer than a week, you’re treating him as a new admit and completing a new admission assessment for him. Although you have a sense of who Mr. Jute is, you don’t know anything yet about his hospitalization and the current state of his nutritional needs.
LTC TIP #1: Assessment expectations
In long-term care, you’re going to be responsible for four specific types of assessments.
- A new admission or readmission assessment
- Quarterly evaluation (happens every 3 months starting from their admission date)
- Annual evaluation (happens every 12 months starting from their admission date)
- Progress notes (usually a short, free-form note completed when you want to communicate with the rest of the team or address new information)
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The Discharge Documentation and the Admission Note
When reviewing the chart for a new patient or a readmission, there are two key documents to review.
- The discharge paperwork
- The nursing admission note
Let’s take a look at both and what you find.
Hospital discharge information
In these discharge documents provided by the hospital, you’re looking for the same kind of information you’d want from any medical chart. This includes:
- Comprehensive or recent PMH
- Possibly an RD note from a previous admission
- Indications of UBW, CBW, or recent wt on admit
- Last diet order
- Recent lab work
- Any IV nutrition support provided during hospitalization (we’ll talk more about this in the next post)
Because you don’t have full access to their electronic medical record, these provided documents are your only access to what was going on with your patient during their admission.
You find the discharge paperwork Mr. Jute uploaded into the EMR. You learn he was admitted with a UTI and acute kidney injury.
You additionally find a surgical note attached in the provided documentation indicating an unexpected debridement of his stage 4 pressure injury.
Labs when he was first admitted show elevated BUN: 31 (H), Cr: 1.3 (H), Na: 133 (L), K+: 4.7 (borderline H) with all having reached normal limits on discharge.
You find no weights and you’re unable to find an RD note included in the paperwork. For this reason, you also don’t know what diet or how he was eating during his stay.
You do see he was provided an IV round of the antibiotic ciprofloxacin for the UTI. Additionally, Mr. Jute was discharged with Doxycycline s/p debridement.
LTC TIP #2: Readmission documentation
Typically when a patient moves from a hospital or another care facility to a long-term care residency, they’ll be accompanied by medical paperwork. Although the admission paperwork will be uploaded into the EMR (unless your facility is still using paper charts), it’s likely to only show up as PDF images. It will be your job to read through that information and determine what you need and what you don’t.
A lot of what’s in those documents may be irrelevant to your job, and it’s not uncommon for this paperwork to either be incomplete or simply unhelpful. However, it’s essential to review because often there will be information you won’t be able to find anywhere else in the chart.
Readmission note
Your next step is to review the new admission note entered by nursing.
Here you can expect to get a clear summary of everything in your patient’s PMH combined with any new information that resulted from their discharge. This is a great place to double check any information you already have and cross check information you’re unclear about.
As expected, nursing confirms the recent UTI with resolved acute kidney injury along with the debridement of the stage 4 sacral pressure injuries and the current use of antibiotics to manage potential wound infection. You also notice nursing has provided Mr. Jute’s with a Heart Healthy diet.
You now know what your patient’s medical state has been for the last 4 weeks. What you don’t know is how that compares to his medical conditions prior to hospitalization and what he now needs to support his nutritional health.
For that, it’s time to review the rest of the EMR.
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Reviewing the EMR
As always, the medical chart is where you’ll find all documented information on your patient. What may not be in the chart is anything that the team has failed to include in their notes. For that missing information, you’ll have to either go directly to your patient or ask the staff responsible.
Reviewing the chart will always give you a good sense of what medical and possibly relevant social issues your patient has experienced since they’ve been a resident.
In long-term care, this will include:
- Complete PMH and a current diagnoses list
- Orders with all the medications they’ve been prescribed
- Dietary information including diet orders, ONS, and sometimes food items
- Referrals completed or pending like SLP evals or HD schedules
- Lab work drawn by your facility
- Weights taken by your facility
- Intake reports completed by a CNA
- Formal evaluations by the medical team
- MDS and the billing section that’s paired with all formal evaluations
What do you need to know to complete Mr. Jute’s readmission eval?
First, current weight status and any recent weight changes must be evaluated.
Second you must confirm Mr. Jute’s diet order, intake, and any changes that need to be made related to his meals.
Third is a look at the existing wounds your patient has and decide on how you’ll care for those.
These are great places to start for all patients. But for Mr. Jute they’re especially notable with his wounds, a standard anticipation of weight loss during hospitalization, and the new diet order submitted by nursing on his readmission.
Let’s take a look at each one.
First - Weight status:
Mr. Jute was weighed by nursing when he returned from the hospital and has a CBW of 127 lb.
For a complete picture, you take a look at his weight history over the last 6 months, in 3 month intervals.
1 month ago: 133 lb
3 months ago from this month: 138 lb
6 months ago from this month: 149 lb
It’s immediately clear that there has been ongoing weight loss, your first big red flag. This is especially concerning considering Mr. Jute had only been admitted to your facility the previous year at a weight of 177 lb.
With weight status being one of the most crucial elements to the work you do in LTC, you need to know the specifics of this weight change. And in doing so, establish his risk of malnutrition.
As required by LTC, you focus on the one and six month markers and discover this:
Weight one month ago:
133 lb, wt loss x 1 month: 6 lb / 4.5%, not significant with weight change under 5% x 1 month.
Weight 6 months ago:
149 lb, wt loss x 6 months: 22 lb / 14.8%, significant with both weight loss over 10% x 6 months and over 10 lbs weight loss in 6 months.
With this information, it’s fair to say Mr. Jute’s is at high risk for malnutrition.
Despite only formally addressing the 1 and 6 month weight changes, it’s relevant to consider the ongoing nature of Mr. Jute’s weight status.
With a total weight loss of 50 lb / 28.2% since he was first admitted a year ago and his loss of 11 lb / 7.9% over the last 3 months, these ongoing weight changes are quite notable. While you might not use them in your formal evaluations, they provide a very useful big picture of Mr. Jute’s declining health.
This kind of context can support your justification when it’s time to determine his most acute issue or have a doctor sign off on your recommendations.
LTC TIP #3: Weight to focus on
In long-term care, weight markers are formally considered at the 1 month and 6 month marks. Simply count back one or three months time and use your professional judgment when deciding to round up to the previous month.
It’s also good to keep in mind that each month the look back of the past 1 and 6 months will always be different. Weight change that wasn’t significant today maybe significant tomorrow which is why paying attention to the overarching trends can be essential.
You may also want to consider how often they’re weighed and how concerned you are about their weight status.
It’s common that monthly weights are expected to be taken for all residents at the start of each month. For those at high risk for significant wt change (for example: malnutrition risk or CHF with water retention concerns), weights may be recommended weekly or even q3d. You may also have a patient on hospice or palliative care who’s quality of life is not improved with managing weight status and they are no longer being weighed at all.
It is well within your scope of practice to make a recommendation to increase or limit the frequency to which your patient is weighed.
Second - Diet order:
Next, you must decide on whether the current Healthy Heart diet order provided by nursing on readmission meets your patient’s needs. Or if you’d like to recommend a new or adjusted diet.
Strictly following MNT, Mr. Jute would be a good candidate for a cardiac diet order. With HTN and CAD, medical nutrition therapy would consider a low Na and low fat nutrition plan acceptable. However you first consider everything you so far know that may directly contribute to his nutritional needs.
To do this, you start by checking the last assessment you completed for Mr. Jute as well as the CNA intake reports both prior to his hospitalization and since his return.
You find your last note written a month before he was hospitalized and discover you had liberalized Mr. Jute’s diet order providing him a regular diet.
You also have written that the CNA reports noted an average intake of 25% of all meals.
With Mr. Jute at high risk for malnutrition because of his significant weight loss, his poor intake further highlights his increased nutritional needs and justifies this liberalized diet order.
Now you also must consider what supplements you’d like to provide Mr. Jute to further improve his health and in turn, his quality of life.
Your previous note tells you Mr. Jute will not eat large amounts of food, so the better option is to provide as many smaller nutrient dense options throughout the day as possible.
Unlike in acute care settings, there are a wide array of food options available in long-term care facilities. This gives you a lot more flexibility in adjusting and tailoring a diet plan specifically for your patients. With a required 3 trays of food each day, you can choose to load up each meal tray with lots of options. You can also choose between-meal snacks.
For Mr. Jute, you decide on a combination of both meal additions and snacks, creating a makeshift small frequent meal diet order.
You start by giving Mr. Jute fortified cereal in the morning and fortified mashed potatoes in the evening with dinner. You include a Magic Cup as a midday snack, and half a sandwich along with his favorite chocolate pudding at HOS. You’re clear to note that he regularly refuses Ensure.
At this point, you must consider his multiple pressure ulcers and determine the support you want to provide specific to this.
LTC TIP #4: EMR vs. food service systems
In LTC facilities, information is often compartmentalized into their own separate online systems. Most notably is often a separate system that houses all food related items including the menus, the diet orders, and available snack items.
Be sure you’re clear where all this information is located in your facility. And then be sure to quickly check every system that holds relevant information on your patient.
Third - Wound care:
Wound rounds were completed the week before your patient had been hospitalized. At that time, you had written a wound note for his three pressure injuries.
They were designated as a deteriorated sacral stage 4 and stable R-heel and L-heel stage 2 pressure injuries. It was also noted that Mr. Jute had been refusing to be turned in his bed and often also refused to join the other residents in dining for dinner, preferring to stay in bed alone.
Included in wound care note are your previous recommendations for nutritional support:
- 15 g Prostat TID
- 220 mg Zinc daily x 2 weeks
- 500 mg Vit C daily
- Encourage fluids of 220 ml TID at MedPass
- Encourage adequate intake of >50% at all meals, snacks
These recommendations along with the recent debridement of the sacral wound during Mr. Jute’s hospitalization makes sense with his progressively worsening stage 4 wound.
You take a look at his current orders to confirm these are still in place and see only the antibiotic Doxycycline Mr. Jute was discharged with s/p his debridement. But you no longer see his added protein, zinc, or Vit C supplements in the current EMR order summary.
LTC TIP #5: Caring for wounds
In most facilities, wound care rounds happen anywhere from once a month to once weekly. You may be asked to join in person but more often, you and the nursing team will meet all together after to discuss each patient. This is your chance to get clarification on any notes that are unclear, verbal information you’ve received, or the status of any wounds that need support.
Keep in mind that as a dietitian, you’re only responsible for providing dietary support for pressure injuries and perhaps, surgical wounds. MASD (moisture associated skin damage), vascular or arterial ulcers, diabetes ulcers are notable but not directly related to dietary scope of practice.
Completed LTC Case Study Review - What have you learned?
You’ve finished your review of the discharge paperwork, the readmission note, and all the information currently in your patient’s chart. And you’ve learned a few key things.
First, your patient needs a new diet order. Rather than keeping their current Heart Healthy diet, you’ll be recommending a change to a liberalized regular diet.
Second, your patient needs their ONS reordered. You may also want to reconsider your patient’s preferences and have a quick chat with them about flavors they’d like, specific foods they want or don’t want, and if there’s anything you can do to further support them meeting their estimated nutritional needs
Third, you need to have their wound supplements also re-added to their orders. No matter what he does or does not choose to eat, there is almost no chance for improved health outcomes without focusing on his wounds.
LTC TIP #6: Counseling residents
Rather than the typical nutrition education and counseling you do in acute care or outpatient work, in LTC, your focus is more often on ensuring the foods provided are foods your patients are willing to eat. Because they are residents of this facility and are supplied with all their meals, you’re providing ongoing and regular MNT for them without the expectation that they’ll be taking any responsibility for food choices.
This means you’re usually tasked with finding new or creative ways to get him to take in enough energy to support his body’s need to dedicate protein to skin integrity and wound healing. Rather than providing education on how to support themselves when they’re on their own.
Finally, are you missing any information?
As always, when you review the information available to you, look for the gaps in what you know or what you can explain. After reviewing the EMR if you’re still missing information, you’ll likely find it talking to the medical team and possibly, to your patient.
Sure, there’s a chance you just overlooked something in the chart. But many times this has nothing to do with something you’ve missed. It’s more about what isn’t available in the chart.
Make a list of things that would make justifying your recommendations stronger or something that might make identifying the most acute nutritional issue easier to do.
Think about things like:
- What did Mr. Jute eat (or not eat) while he was hospitalized?
- Are there any foods he wants or doesn’t want at meals anymore?
- Is he willing to take his food supplements (assuming his protein is provided at MedPass from nursing)?
Some of this information you might not have access to and that’s ok. Do your best and if there’s something you don’t have an answer to that might have otherwise changed the way you provide your interventions, make sure you note that in your assessment.
And That’s It!
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Looking for a more in-depth walk through on how to start talking to this kind of patient? Start with the Clinical Case Studies done live every month. Click here to watch all the replays and sign up for our next live.
Ready to talk about how to do some charting on this patient? Check out the next post that takes everything we’ve talked about here and translates it into a nutrition assessment summary, some interventions, and get you thinking about possible PES statements.
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