"T

his is going to be a very long day," I mumbled aloud. I was conducting a chart audit at a nursing home, and the very first chart I looked at had me frustrated. Beads of sweat were forming on the back of my neck as I waited for an answer to what I thought was a very simple question. "What is Mrs. McCall's current diet order?" I asked. The nurse replied, "Well, let's just look that right up," as she proceeded to grab Mrs. McCall's chart and turned to the physician order sheet. In just a few seconds, she announced that the diet order was No Added Salt (NAS). Of course, I had seen that same order, but I also saw a telephone order for a mechanical soft diet and another one for pureed meats. Were all these orders current? Did one supercede another?
       The nurse couldn't say for certain, so I asked a second nurse. She determined that the order was mechanical soft with pureed meats, because those orders were dated later than the order for NAS and, therefore, were more current. The dietetic technician then got involved and informed both nurses that the order really should be NAS mechanical soft with pureed meats, because Mrs. McCall had hypertension and still needed the NAS part of the restriction. So there I stood trying to sort out this diet order dilemma when a thought occurred to me--I could go to the dining room and look at Mrs. McCall's tray card and see what she was actually served today. When I got to the dining room, I found Mrs. McCall staring at her tray, which contained a NAS mechanical soft diet with pureed meats. The tray was essentially untouched, so I asked her why she wasn't eating. She replied, "I would eat if I could just have regular food. I told them I want regular food, but no one does anything." So there we had it--a fourth opinion in the case of the complex diet order, and I was only on the first chart of the day.

Types of Diet Modifications
       Diet orders fall into two broad categories--therapeutic orders and texture modifications. Therapeutic orders are diet modifications that are instituted to treat a disease state. For example, a NAS diet is often ordered as an intervention for hypertension. Other therapeutic diets include No Concentrated Sweets (NCS), low cholesterol, American Diabetes Association (ADA) diets, low fat, high fiber, low residue, and many others. Texture modifications are orders that modify the consistency of the food to ease chewing and swallowing problems, fatigue that may occur during meals, or dexterity problems. Typical texture modifications include mechanical soft diets and orders for chopped or pureed foods.
       Confusion often ensues when a new order is written to modify one of these categories but not the other. In the case of Mrs. McCall, she was admitted with a NAS diet order to treat her hypertension. The texture modifications were added later, but it was unclear to the staff whether the new orders took the place of the old order or were simply an addition to the existing order. Each facility must have a clear policy on how to handle this common situation.

Keep it Simple
       The sheer number of different diet orders and combinations can become unmanageable and confusing. The first step to simplifying diet orders is to conduct an audit and determine how many different diets and combinations have been ordered in the past six months and how frequently. Each time a different diet is ordered, it requires a corresponding menu and creates more opportunities for errors. Additional diet plans also increase labor and food costs, so it is wise to simplify. It is up to each individual facility to determine how many diets are feasible and necessary. A policy should outline the diets that are available. This must be communicated to all the physicians and the interdisciplinary team so that there is a defined way to handle orders. For example, sodium restrictions can be ordered in many ways. Common orders may include low sodium, 2-gram sodium, 3-gram sodium, 4-gram sodium, NAS, and low salt. The facility policy should clarify how these different orders are interpreted.

Diet Liberalization
       Diet liberalization is based on the belief that the quality of life for nursing home residents and older adults in general may be enhanced by less restrictive diets. Diets that are very restrictive may not be as tasty or palatable as less restrictive diets and may contribute to poor food and fluid intakes. Involuntary weight loss (IWL) is a concern for most facilities, and a more liberal diet may be one strategy to combat this problem. The benefits of a therapeutic diet should be carefully weighed. Of course, there are residents whose conditions warrant dietary interventions. For example, a resident with an acute disease process or a newly diagnosed medical condition may require intense nutrition intervention. But many residents suffer from chronic diseases that may not require dietary limitations and, in fact, may benefit from a less restrictive meal plan if it increases meal consumption. Overly restrictive diets may be too low in calories, bland, and lack eye appeal. If the diet restriction offers health benefits that justify its use, then the restriction should be followed. In many cases, however, the restriction can be lessened without any negative consequences or ill effects.

Documentation Issues
       Regulations require that physicians' orders are followed, but sometimes it is difficult to determine from the documentation exactly what was done to carry out the order. From a risk management perspective, diet orders that may cause confusion include orders to encourage and restrict fluids and serve small and large portions. Clear policies can avoid any ambiguities that may result from general orders, such as these. If a resident is to receive small portions, exactly which parts of the meal are reduced? How does this affect the meal intake log? For example, if a small portion diet is 75 percent of the usual amount of food served and the resident consumes 50 percent of the meal, how is that documented? If a house diet is 2,000 calories and 50-percent intake is documented, it may appear that the resident consumed approximately 1,000 calories. But 50 percent of a small portion diet is really more like 750 calories. It can be quite confusing unless there are policies and procedures to guide practice.
       Consider an order to encourage fluids. If you had to review a chart from last year that contained this order, would you be able to clearly show how this was carried out from looking at the facility policy and the chart notes? Pretend you are defending your facility in a legal matter, and it is your job to demonstrate how this order was executed. Would the notes state that fluids were encouraged? How many times per day? What type of fluids? Were the fluids consumed?

Resident's Rights
       Every resident has the right to refuse a diet order if he or she is competent to make that decision and understands its impact. Resident refusal and nonadherence to a diet must be carefully documented in the medical record. Nutrition education and counseling should be used to help the resident understand why a certain restriction is necessary. If the resident still chooses to refuse the nutrition intervention, this should be respected, and the diet order should be changed. The most difficult issues arise when a resident does not adhere to an order that impacts the safety of the resident. For example, if a resident does not accept thickened liquids, which are ordered to minimize the risk of aspiration, the resident may put his or her medical condition in jeopardy. Each facility must have a clear policy that outlines the steps to take when this situation arises.

Diet Orders are Everyone's Business
       At first glance, diet orders may seem to be the domain of the dietary department, but clearly, they impact the entire staff. With so many decisions to be made, it is best to form a nutrition team with representatives from each department to decide how to handle the issues presented by diet orders. With a little planning and forethought, diet orders don't have to be a dilemma any longer!