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FAQ for LTC Professionals |
Menus
Q. Our menus are prepared by our food vendor. They have many items on them our residents do not like and the vendor does not make individual facility changes. My administrator has instructed me to go ahead and make the changes as this is what our residents want us to do. Can I do this?
A. The menus served in long-term care must meet federal regulation (and any state regulations that may be more strict), and the USRDA for the population in the facility; must be appropriate for the resident population, prepared in advance and followed.
Review the F363 Menus and Nutritional Adequacy requirement, your state regulation for menu requirements, and discuss any proposed menu changes with the dietitian. The dietitian needs to approve any menus or proposed menu changes; and assure they are nutritionally equivalent to the original items and that therapeutic diet menus are appropriately completed as well.
Safety
Q. When should foodservice workers wear disposable gloves?
A. First of all, a worker must wash their hands before putting gloves on. Gloves must be worn whenever a worker is directly handling a food item. Gloves are not a substitute for appropriate and through hand washing. Hands must be washed in between changing gloves. Replace gloves at least hourly or when changing food preparation tasks, after sneezing, coughing, touching hair, face, and any other contaminated surfaces.
Q. When using the two-stage cooling process, what if we can’t get the temperature of the food to 70 degrees F within the first two hours?
A. The two-stage cooling process is the rapid cooling of a food product through the temperature danger zone. (Check with your state health department to verify the temperature danger zone for your state). You must cool a food item from 140 degrees F to 70 degrees F within two hours and from 70 degrees F to 41 degrees F within four hours. If the temperature of 70 degrees F or below has not been reached within the first two hours, you may reheat the food one time only and try cooling by a different method or you must discard the product.
Q. We recently had a resident burn themselves by spilling hot coffee into their lap. He received second degree burns to his inner thighs. The coffee was 150 degrees when served to him. Is there any regulation as to how hot a hot beverage or other hot food should be or a maximum temperature in the Regs? for hot food/beverage?
A. This is certainly an undesirable occurrence in LTC facilities. As far as we know there is no regulation that stipulates an upper level for hot foods or beverages. And, of course with the requirement to keep hot foods and beverages at both safe and palatable levels of 140 degrees or greater, there can be a concern of how hot is “too hot”.
While many people like their coffee or other hot beverage in the 170-200 degree range, this can present a risk to facility residents who are cognitively impaired, have weakness or are fatigued, have difficulty with motor skills, or just require assistance to eat and drink. These residents need to be monitored closely by staff at meals—perhaps including this risk in the resident’s individual care plan, and possibly conducting a staff training program on how to safely serve hot beverages or soups.
Many facilities have adopted a policy of hot beverages leaving the kitchen between 130-135 degrees. We suggest you discuss developing a policy that is appropriate to your facility residents—with the administrator, Director of Nursing, and Dietitian—addressing hot beverage temperature ranges that are acceptable upon leaving the kitchen, a training program for staff as well as the individual needs of residents who need extra assistance or monitoring at meals.
Q. We recently received an F371 tag for a resident who wants her food “lukewarm.” We prepare her tray anywhere from 30 to 60 minutes ahead of her receiving it. Hot foods usually are between 100 and 120 by this time and cold foods are usually 55 to 70 degrees. She is then served the tray and since she prefers to eat very slowly (and without assistance from staff) we leave the tray with her as long as she wants—sometimes up to 2 hours after being served. The survey cited F371 and that all hot foods had to be 140 degrees or greater. But this is what the resident is accustomed to and wants. Doesn’t the resident have a choice in this matter?
A. F371 does stipulate that foods (both hot and cold) are served at safe and palatable temperatures. According to the Federal Food Code this is 140 degrees or greater for hot foods (especially potentially hazardous hot foods-PHF) and 41 degrees or less for cold foods. However, it is the resident’s right to have foods served to her at a temperature that she prefers—this should be clearly addressed in her care plan with regular reviews to see that the goals and approaches continue to be appropriate and meeting her needs. Also, chart notes should clearly indicate this preference and how you are handling it.
We would suggest a limit of 2 hours on food that is left in the danger zone of between 41 and 140 degrees—as this is the upper limits of safety for preventing pathogen growth in PHF. This may have been the surveyors’ primary concern. It’s always good to ask questions and fully understand the surveyors concerns before the exit is done.
Nutrition
Q. Our facility was recently cited for not addressing weight gain in an overweight resident. The resident did not have any of the “significant” weight gains that we look for monthly (e.g. 5% or greater 1 month, 7.5% or greater in 3 months, and 10% or greater in 6 months). She went from 155 to 173 lbs. in a 9 month period. The resident is on a General diet and enjoys her meals thoroughly as well as the foods provided at activities and that her family brings in. Is this appropriate?
A. The F325 Guidelines for Surveyors are in the process of being rewritten and finalized to more fully address a “continuous, progressive or insidious weight gain or loss”—in addition to the “significant weight change parameters” we are accustomed to and that you have referred to.
Unintended weight loss (UWL) and Unintended Weight Gain (UWG) can be detrimental to residents’ health and quality of life in long-term care facilities. UWG can cause decreased mobility and functional independence due to excess weight, impaired glucose levels, increased risk for pressure sores due to decreased mobility and additional weight on bony prominences—just to name a few possible problems.
There are many factors that can impact a resident’s weight, including medication side effects, resident’s own wishes and plan, medical diagnoses and any chronic conditions, and any current functional or psychological considerations. These should be fully evaluated by the dietetics professional, with specific goals and plan, and indicating what can be anticipated for the resident weight in the future.
We do need to be looking for these UWL’s and UWG’s on a regular basis. Our staff routinely looks for any weight “trends” occurring over the past 1 year, as well as any of the “significant weight changes” in 1, 3, and 6 months. There is no set standard for “trends;” however, the resident you described would fit into this category. Some dietitians look for a continuous 1-3 lbs. gain every month for 6 months or so.
Q. Our medical director states he wants the menus in our facility to have between 1400 to 1700 Calories. He feels the current menus (the general menus contains between 2000 and 2300 calories) are too much for his geriatric residents and is concerned it will lead to obesity, worsening coronary diseases, more Type II Diabetes, etc. However, our state regulations specify a minimum of various types of foods be served to our residents daily and the residents like our menus the way they are. What can I do?
A. It’s true, you do have to follow regulatory guidelines for the menus—based on federal guidelines as well as any state guidelines you are required to follow. You might use the Limited Concentrated Sweets or Consistent Carbohydrate diet with skim milk and limited fats to help limit calories for those whose excess weight is a health concern—this would bring calories down to possibly 1600-1900 calories a day being provided.
It’s important to remember that residents have the right to have a diet and menu that they prefer, and may also eat a variety of snacks at activities or other social events as well as have foods brought in by visitors. Appropriate snacks of lower calorie should be available for residents at activities with counseling by nurses or other professional staff of the possible problems associated with eating foods not on their diet or too many calories. And, of course, the care plan needs to address non-compliance to diet or concern for weight gains.
We suggest you explain these options to the Administrator as well as the medical director and see what plans can be put in place that will meet the state and federal regulations as well as address the physician’s concerns.
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