New way of feeding residents in long term care nursing homes

[busyrn92]

I work in one of the largest homes in the US as a unit manager. Long term care is new to me after over 20 years of acute care experience in critical care/ER. This position is challenging-I am responsible for the care of 41 residents and handling issues with a total of 24 staff members (LPNs and CNAs). About two weeks ago (I only started as unit manager 3 weeks ago), I was informed by the head of the dietary department that my unit was chosen out of 24 units to become a pilot for a new way of serving our residents. I was told that the CMS no longer allows the staff in a long term care facility to simply place a meal try in front of a resident, and that this new (they call it "Culture Change") would be a way to make it more "home-like for the residents."

I was actually looking forward to this.

Well, the day came and the new system (or lack of system) turned out to be very chaotic. My typical day begins at 7:30 am. I get report from the night shift supervisor, quickly check my email to make sure that I am prepared for meetings that days, and assist the staff with getting residents up and washed in time for breakfast. At about 7:45, the dietary aides appear on the floor and begin to set up a food cart that is now left in our recreational room, along with a tall refrigerator filled with juices, puddings, fruit, etc. There are two dietary aides. At 8 am, it is all hands on deck-the unit secretary and every nurse and CNA must drop what he/she is doing in order to participate in this new procedure. Two CNAs run around to the 16 residents who prefer to eat in their rooms; the rest of us begin to serve the residents who eat in the dining room by giving them placemats, silverware, and coffee cups. We pour coffee and hot tea for everyone. The staff pick up each menu (it has the type of diet the resident is on) and ask the resident "would you rather have pancakes or an omelette?" They continue to ask which juice they want; when that is done, each staff member then hands between 6-8 of these menus to the dietary aide whose job it is to read it out loud to the the other aide. The second dietary aide dishes out the food onto each plate. The staff then deliver each plate to the correct resident. Many of our residents are either hard of hearing, have problems with vision, have intellectual disabilities or advanced dementia, and/or have had a stroke. Thickener must be added to liquids for those residents who are on aspiration precautions. All of us are cutting up food and assisting those who need help or pouring coffee or doing any number of meal-related activities. Meanwhile, the phone is ringing off the hook and the two staff nurses are getting behind in their med passes. I cannot do anything other than assist with the meals because there are usually only 3-4 CNAs scheduled and the majority of our residents have to have continence care prior to eating. After everyone is finished eating, we must bus our tables-separating dishes, forks/knives/spoons/glasses/cups and scraping left over food into the trash cans. The dietary aides do nothing other than what I already described. Before you know it, it is time for lunch and the whole thing starts up again. I met with the director of the dietary department the day before the Culture Change was started and asked if he had anything in place to make this transition easier; he was surprised that I asked him and said "That's NURSING's JOB." I ended up making a seating chart (labeled the residents who sit at each of the six tables and their diets) and a list of the residents who prefer to eat in their rooms. I coached the staff for all three meals, asking them to choose two CNAs for each meal to deliver the food to the residents who eat in their rooms first. I have been staying until dinner is over every single day so that I can help and make sure that my staff is given some support.

On the second day of the Culture Change, an important person from Administration came to my floor to see how well this process was going. I did not recognize her because she did not introduce herself to me and she was not wearing a badge. This person thought that the new Culture Change "was chaotic and unorganized" and reported me to the DON. I was called to the DONS's office about a week ago, where she yelled and criticized me for not doing a better job. When I asked for some guidance, she actually screamed "YOU are the Unit Manager-FIGURE IT OUT!" That was followed by a humiliating comparison where she was unfavorably comparing me with the last unit manager. I was warned that I "better figure this out or I am going to be canned."

I have since contacted the director of food services to see if he had any ideas about how we can make this transition go smoother. I did ask the DON for a Nursing Policy and Procedure about the Culture Change, since there is a nursing policy about every thing else. I was told "there is none-this is just an initiative."

Does anyone have any advice for me? When I asked the DON "So, all hands on deck at mealtime?" she yelled at me and said "Figure that out yourself!"

[calivianya, BSN, RN]

Sometimes I complain about being treated like a waitress. It sounds like you and your staff are turning into waitresses for real! I got a headache just reading about your frustration. Do you have the power to hire additional staff? It sounds like you need some dedicated staff for meal times - someone who can take the patient's order and put food together.

Barring that, I'd seriously consider getting out of there. I would be livid if my manager talked to me the way the DON talked to you. That alone would just about be enough for me to be out of the door.

[jadelpn, LPN, EMT-B]

It is very troubling that the response to this initiative was "figure it out". Sounds to me like the "initiative" is that nursing now adds the job of dietary to their already full plate. (pun intended)

I would direct the 2 dietary aides to do a whole lot more in this process than just stand and wait for people to finish. THEY need to be bussing tables, for instance. Do they not want to hire more dietary aides?

If they could supply menus in the evening, then the CNA's can discuss with the resident meals. Then, you could in fact save time by just bringing plates to the residents. The night CNA's could set the breakfast tables. The dietary staff could set up for lunch at 11am, the evening meal could be set up at 4pm, again by dietary staff.

The other thought process is that you have per diem CNA's who come in as "meal companions" and work 7a-9a, 11a-1p, and 4p-6p and do specifically meals. And there are many CNA's who like to just work a couple hours here and there. You could also coordinate your occupational therapy during part of meals, swallow evaluations....

If there is a core volunteer group for the home, speak with activities regarding their assistance at meal time.

Finally, I would also have the med nurse help deliver a meal, give the resident meds, and so on. It may only get a few meals out, but it would be a few meals out.

I am sure this is in response to some sort of "we pay good money for gramma to be here, WHY is it not home like, rather institutionalized food?!?!?!" And more than likely, a large donation, and senior administration is all ears.....

[mrsboots87]

We have a similar set up at my LTC, except dietary does a lot more then just stand there and scoop food. It's their job. We have two aids work the floor for the residents who eat in their room and to answer call lights for those who get back from the dining room quickly. The rest of the staff help in the dining room. It's works like this.

-After dinner before dietary staff go home, they pass out the next day's menu to all the residents and assist with coining the meals for those that can't write anymore.

-Then for each meal the next day dietary staff set the tables with placemats, silverware, and coffee/tea/water

-while dining room residents are brought in by CNAs, dietary prepares the room trays on a cart and brings it to the floor

- then one dietary aid reads off orders while another prepares the dish

- once a plate is done it is pushed out to a waiting table for a nurse or CNA to bring to a resident

-after all residents are served in the dining room, the CNAs (3-5 depending on the shift) help the feeders and supervise the aspiration precaution residents while the nurses continue their evening med pass

- after dinner, the CNAs bring residents back to their rooms and begin PM care and bedding of residents, while dietary cleans up the dining room.

This is works well and everybody helps.

How did meal service work before? If dietary served and bussed before, why are they having a fit about it now? If the DON is yelling at you (that's extremely unprofessional and a huge red flag) then tell her you need support is asking dietary to do more. This simply will not work by adding more duties to the already strained nursing staff. The residents will get less care, meds will run late, and dietary will be done early and have a much easier shift while you are getting termed by the DON. Doesn't sound conducive to a team environment at all.

And if in understanding correctly, all the residents who need PM care and toilet in and such are being attended to by 2 CNAs to 41 residents while the rest of the staff is cleaning up the dining room. Just sounds like a disaster.