RAI-MDS 2.0 Nutritional Care Resource Guide April 2011 - CCIM

RAI-MDS 2.0 Nutritional Care Resource GuideApril 2011For Information: 416.327.7625ltchrai@ontario.ca

Non-production Clause© Baycrest Centre for Geriatric Care [September 6, 2007]. These educational materials may be copied or distributed withoutpermission solely for educational and implementation purposes, provided that (i) the copyright notice is reproduced on allcopies, and (ii) these materials are not modified in any way, nor provided or distributed alone or in conjunction with any othermaterials, for money or other consideration.These educational materials are provided by Baycrest Centre for Geriatric Care through the Long-Term Care Homes CommonAssessment Project (LTCH CAP) and are designed for use with the education and implementation support program providedby LTCH CAP. These materials alone are not sufficient for a successful and complete RAI-MDS 2.0 implementation.For Information: 416.327.7625ltchrai@ontario.ca

Table of Contents1. Chapter 1: RAI-MDS 2.0 Introduction2. Chapter 2: RAI-MDS 2.0 Assessment3. Chapter 3: Resident Assessment Protocols (RAPs) and Plan of Care4. Chapter 4: RAI-MDS 2.0 Outputs and Reports5. Chapter 5: AppendicesFor Information: 416.327.7625ltchrai@ontario.ca

CHAPTER 1: RAI-MDS 2.0 IntroductionCHAPTER 1: RAI-MDS 2.0 Introduction................................................ 1Glossary of Terms ................................................................................ 2RAI-MDS 2.0 Overview for Nutrition Team .......................................... 3Getting Started Checklist .................................................................. 14

Glossary of TermsADLAlgorithmAverage weight forht/sex/ageARDBody mass index (BMI)CHESSCIHICPSDARTDRSGoal weight (GBW)IDTISELTCH CAPMDSNutrition Care TeamQIRAIRAPsReliabilityRUGsSection VTriggersUsual body weight(UBW)ValidityActivities of daily livingA precise rule (or set of rules) that specifies how certain problems should be solved.RAI has built-in algorithms for RAPs, outcome measures and RUGs.Weight defined in reference tables, which outline the average weight of individualsaccording to age, sex and height (Master, Laser, Beckman 1960, NHANES). Thisterm is sometimes referred to as ‘ideal body weight’ range (IBW).Assessment Reference Date, the last day of the assessment observation periodCalculated by weight (kg)/height (m) ². For persons 65 years and older, the ‘normal’range may begin slightly above BMI 18.5 and extend into the ‘overweight’ range(Health Canada). Healthy range also varies among ethnic backgrounds.Changes in Health, End-stage disease and Signs and SymptomsCanadian Institute for Health InformationCognitive Performance ScaleData Accuracy Review TeamDepression Rating ScaleThe target weight based on individual’s usual body weight and clinical assessment ofnutrition riskInterdisciplinary TeamIndex of Social EngagementLong-Term Care Homes Common Assessment ProjectMinimum Data SetThe primary nutrition care team includes clinical dietitian, nutrition manager andnursing. They will consult other care providers for nutrition information, ifappropriate.Quality indicatorResident Assessment InstrumentResident Assessment ProtocolsDo you get the same answer regardless of who is doing the assessment?Resource Utilization GroupsResident assessment protocol (RAP) summary formThe RAI-MDS 2.0 assessment items that group to form the algorithm(s) to initiate theRAP(s)Weight that an individual has maintained for an extended period of time. UBW is themost important factor in assessing weight changes.Does the instrument measure what it purports to measure? Are the relevant conceptscovered?For Information: 416.327.7625 2ltchrai@ontario.ca2

RAI-MDS 2.0 Overview for Nutrition TeamWHY IMPLEMENT RAI-MDS 2.0 IN ONTARIO’S LTC HOMES? RAI-MDS 2.0 provides better assessment and care planning Good assessment is the foundation for a comprehensive nutrition care planRAI-MDS 2.0: RESIDENT BENEFITS RAI-MDS 2.0 provides a holistic interdisciplinary assessment of resident care needs and the development ofan individualized plan of care that reflects resident’s strengths, preferences and goals Identifies actual and potential resident care needs, concerns and risks in a timely fashion Encourages resident and family involvement Respects the value of helping residents achieve their highest level of functioning and quality of lifeRAI-MDS 2.0: CARE TEAM BENEFITS Strengthens interdisciplinary care delivery process by:- Identifying residents’ needs and interventions more effectively- Determining the root causes of needs and concerns- Helping to plan and implement individualized care- Providing clear and comprehensive information for evidence-based clinical decision making Monitors quality by:- Tracking resident-specific outcomes- Monitoring resident change over time Promotes researchRAI-MDS 2.0: MANAGER BENEFITS Provides comprehensive and timely information and reports for quality improvement, performanceassessment, benchmarking and accreditation Compares, measures and tracks health outcomes (over time / across sites of care) Supports clinical best practice, strategic planning, program evaluation, quality improvement activities,resource allocation as well as clinical and operational reviewsRAI-MDS 2.0: MINISTRY BENEFITS Provides comparable data locally, regionally and nationally to support resource needs evaluation andallocation Delivers effective ways to measure quality Enhances availability of quality and comprehensive data for province-wide benchmarking, policydevelopment and system planningRAI-MDS 2.0 INSTRUMENT Is a reliable, validated and interdisciplinary assessment tool Completed on admission, quarterly, annually and upon a significant change in status Identifies the majority of a resident’s strengths, needs and preferences Captures residents care needs over 24 hours Includes a full and a quarterly assessment tool- Full assessment tool contains 20 sections and over 450 items- Quarterly assessment tool contains 18 sections and over 300 itemsFor Information: 416.327.7625 3ltchrai@ontario.ca3

RAI-MDS 2.0 Target population:Frail elderly and disabled adults in long-term care settingsRAI-MDS 2.0 was developed by: The Health Care Financing Commission (now CMS) The Research Triangle (Hebrew Rehabilitation Centre for the Aged in Boston, The University of Michiganand Brown University) Expert health care consultants and Advisory panels: nurses, doctors, physiotherapists, occupationaltherapists, speech therapists, activities therapies and nutritionists Others: consumers, resident advocates, nursing home industry representatives, regulators andmeasurement specialistsinter-RAI Suite of Instruments (www.interrai.org):Acute CareAssisted LivingCommunity Mental HealthHome CareIntellectual DisabilitiesLong-Term Care FacilitiesMental HealthPost Acute CarePalliative CarePersons with DisabilitiesinterRAI ScreenerCIHI RAI-MDS 2.0 USER’S MANUAL (UPDATED SEPTEMBER 2010) Helps with coding and is critical for maintaining and enhancing data quality Addresses each coding item with:o Intento Definitiono Processo Coding choiceso Offers helpful exampleso Includes CIHI tips* Contact www.cihi.ca to obtain the new version of the RAI-MDS 2.0 User’s Manual (September 2010).For Information: 416.327.7625 4ltchrai@ontario.ca4

HOW IS THE RAI-MDS 2.0 FULL ASSESSMENT STRUCTURED?There are 20 Sections on a full RAI-MDS 2.0 assessment AA and A Identification information AB, R Assessment information B-Q, U Focus on resident functionSECTION A, AA AND AB: IDENTIFICATION AND BACKGROUND INFORMATIONINTENTResident’s personal information, including legal responsibility, admission and discharge detailsSECTION B: COGNITIVE PATTERNSINTENTResident’s ability to remember, think coherently and organize daily self-care activitiesEXAMPLES: Comatose, memory and memory recall, delirium etc.SECTION C: COMMUNICATION/HEARING PATTERNSINTENTResident’s ability to hear (with assistive devices if used), understand and communicate with othersEXAMPLES: Hearing, communication devices, speech clarity, ability to understand others etc.SECTION D: VISION PATTERNSINTENTResident’s visual abilities and limitations over the past seven days, assuming adequate lighting andassistance of visual appliances, if usedSECTION E: MOOD AND BEHAVIOUR PATTERNSINTENTFrequency of indicators of depression, anxiety and sad mood observed in the last 30 days, irrespective ofthe assumed cause of the indicator (behaviour)For Information: 416.327.7625 5ltchrai@ontario.ca5

SECTION F: PSYCHOSOCIAL WELL-BEINGINTENTResident’s emotional adjustment to the facility, including his/her general attitude, adaptation to surroundingsand change in relationship patternsEXAMPLES: Sense of initiative/involvement, unsettled relationships etcSECTION G: PHYSICAL FUNCTIONING AND STRUCTURAL PROBLEMSINTENTResident’s self-care performance in ADL during the last seven days (how much they did, how much verbalor physical help was required from the staff)EXAMPLES: Bed mobility, transfer, dressing, eating, toilet use, bathing, test for balance, modes of transferSECTION H: CONTINENCEINTENTResident’s pattern of bladder and bowel continence (control) over the last 14 daysEXAMPLES: Bowel continence, bladder continence, elimination pattern etc.SECTION I: DISEASE DIAGNOSESINTENTPresence of diseases that have a relationship to the resident’s current ADL status, mood or behaviourstatus, medical treatments, nursing monitoring or risk of deathEXAMPLES: Anxiety disorder, Congestive Heart Failure, Cerebral Palsy etcSECTION J: HEALTH CONDITIONSINTENTSpecific problems or symptoms that affect or could affect the resident’s health or functional status, as wellas risk factors for that illness, accident and functional declineEXAMPLES: Problem conditions, pain symptoms, pain site, accidents, etc.For Information: 416.327.7625 6ltchrai@ontario.ca6

SECTION K: ORAL/NUTRITIONAL STATUSINTENTOral and nutritional problems present in the last seven daysEXAMPLES: Oral problems, height and weight, nutritional problems, nutritional approaches etc.SECTION L: ORAL/DENTAL STATUSINTENTResident’s oral and dental status as well as any problematic conditionsEXAMPLE: Oral status and disease preventionSECTION M: SKIN CONDITIONINTENTNumber of ulcers/open lesions, of any type at each ulcer stage, on any part of the body. Also, to documenttreatments for active skin conditions and any protective skin or foot care treatmentsEXAMPLE: Ulcers, type of ulcer, skin treatment, foot problems and care, etc.SECTION N: ACTIVITY PURSUIT PATTERNSINTENTThe amount and types of interests and activities that the resident currently pursues, as well as activities theresident would like to pursue that are not currently available at the homeEXAMPLES: Time awake, average time involved in activities, preferred activity setting, etc.SECTION O: MEDICATIONSINTENTThe number of different medications (over-the-counter and prescription drugs) the resident has received inthe past seven daysEXAMPLES: Number of medications, new medications, injections, etc.For Information: 416.327.7625 7ltchrai@ontario.ca7

SECTION P: SPECIAL TREATMENTS AND PROCEDURESINTENTAny special treatments, therapies or programs the resident received in the specified time periodEXAMPLES: Special treatment, procedures and programs, nursing rehabilitation/restorative care, etc.SECTION Q: DISCHARGE POTENTIAL AND OVERALL STATUSINTENTResidents who are potential candidates for discharge within the next three months.SECTION R: ASSESSMENT INFORMATIONINTENTThe participation of the resident, family and/or significant others in the assessmentSECTION U: MEDICATION LISTINTENTIdentifying potential problems related to polypharmacy, drug reactions and interactions.Please Note: Completion of Section U is not mandatoryDIETITIANS USE INFORMATION THAT OTHER TEAM MEMBERS HAVE COLLECTEDThe RAI-MDS 2.0 collects information such as: Ability to see (Section D) Ability to hear (Section C) Physical Functioning and Structural Problems (Section G) Continence (Section H) Condition of skin (Section M) Medical Diagnosis (Section I) Oral/Dental Status (Section L)Dietitians/nutrition managers can review this information and use it as needed. It does not have to be written down ona separate nutrition assessment formFor Information: 416.327.7625 8ltchrai@ontario.ca8

RAI-MDS 2.0 MODELRAPS FOR PLAN OF CARE• Based on the coding of the RAI-MDS 2.0 assessment• Identify possible additional assessment or intervention needs• Cover issues that are common in target population or pose severe risks• Help dietitian and nutrition manager focus on key nutrition care issues• Provide an important link between the RAI-MDS 2.0 assessment and care planning• Replace quarterly narrative summary documentation for all interdisciplinary team membersTHERE ARE 18 RAPS:• Delirium• Cognitive Loss/Dementia• Visual Function• Communication• ADL Functional/Rehabilitation Potential• Urinary Incontinence and Indwelling Catheter• Psychosocial Well-Being• Mood State• Activities• Behavioural Symptoms• Falls• Nutritional Status• Feeding Tubes• Dehydration/Fluid Maintenance• Dental Care• Pressure Ulcers• Psychotropic Drug Use• Physical RestraintsFor Information: 416.327.7625 9ltchrai@ontario.ca9

SECTION V – RESIDENT ASSESSMENT PROTOCOL SUMMARYMONITORING AND EVALUATION SYSTEMSEmbedded within the RAI-MDS 2.0 are various scales and IndicesQUALITY INDICATORS (QIS) There are 35 QIs Can be used to:- Identify exemplary care- Help staff to track quality of care- Identify potential care problem areas/quality concerns- Target staff education for care improvement- Identify residents at risk for monitoring the outcomes of care over timeDomainQuality IndicatorsPHYSICAL FUNCTIONActivities of Daily LivingMobilityWorsened early-loss ADL; improvedWorsened mid-loss ADL; improvedWorsened late-loss ADL; improvedWorsened ADLWorsened locomotionImproved locomotionFor Information: 416.327.7625 10ltchrai@ontario.ca10

DomainQuality IndicatorsPSYCHOSOCIAL FUNCTIONBehaviourCognitive FunctionCognitive FunctionCommunicationDeliriumMoodWorsened behavioural symptomsImproved behavioural symptomsWorsened cognitive abilityImproved cognitive abilityWorsened cognitive abilityImproved cognitive abilityWorsened communication abilityImproved communication abilityHas deliriumWorsened mood – symptoms of depressionSAFETYMedicationsFallsInfectionsTaken antipsychotics without a relevant diagnosisFallen (in last 30 days)Has an infectionWorsened/unchanged respiratory infectionPressure Ulcers Has a pressure ulcer at stages 2 to 4Worsened pressure ulcer at stages 2 to 4Has a new pressure ulcer at stages 2 to 4RestraintsDaily physical restraintsOTHER CLINICAL ISSUESContinenceNutrition/WeightPainHas an indwelling catheterWorsened bowel continenceWorsened urinary continenceHas a urinary tract infectionImproved bowel continenceImproved bladder continenceHas a feeding tubeHas had weight lossHas painWorsened painFor Information: 416.327.7625 11ltchrai@ontario.ca11

OUTCOME SCALES OR MEASURES• 10 outcome measurement scales• Outcome Scales can help to improve clinical practice by:- Identifying resident specific or aggregate information on resident care needs and outcomes- Tracking clinical outcomes (e.g. pain)- Monitoring resident change over time- Evaluating the effectiveness of clinical interventions- Targeting staff education for clinical improvementScaleCognitive Performance Scale (CPS)Depression Rating Scale (DRS)Activity of Daily Living (ADL Short Form, ADL Long Form, ADLHierarchy)Changes in Health, End-Stage Disease and Signs andSymptoms Scale (CHESS)Index of Social Engagement (ISE)Pain ScaleAggressive Behaviour ScaleinterRAI Pressure Ulcer Risk ScaleMeasuresLevel of cognitionLevel of depressionADL performanceFrailty and instabilityDegree of social engagementPrevalence of painAggressive BehaviourPressure Ulcer RiskUTILIZATION GROUPS RUG-III• Upon completion of the RAI-MDS 2.0, the software automatically classifies residents into 7 major groups• Residents are grouped according to their clinical and diagnostic characteristics and resource utilization• RUGs can help to:- Compare resident profile, resource requirements and utilization by unit, and by types ofresidents- Trend resource intensity over time to validate workload- Determine staffing pattern- Assign appropriate skill mix to care unitFor Information: 416.327.7625 12ltchrai@ontario.ca12

RUG Group 34 Sub-Groups Case Mix Indices (2009)Extensive Services 3 1.4460 - 1.9422Special Rehabilitation 4 1.0167 - 1.6125Special Care 3 1.2135 - 1.4020Clinically Complex 6 0.9413 - 1.3793Impaired Cognition 4 0.7177 - 0.9729Behavioural Problem 4 0.6327 - 0.9388Reduced Physical 10 0.6308 - 1.1291For Information: 416.327.7625 13ltchrai@ontario.ca13

Getting Started ChecklistCompletionAction ItemDate1. Find out the home’s RAI-MDS 2.0 Kick Off date, time and location2. Communicate the Kick Off information to nutrition care team members and ensure their attendance3. Following the Kick Off, arrange a meeting with the RAI Coordinator to:- Set up regular meeting date and time to discuss RAI-MDS 2.0 implementation- Identify tool(s) or resources to get ready for RAI-MDS 2.0 coding implementation e.g. print therelevant information from the RAI-MDS 2.0 User’s Manual – Sections K&L for coding reference- Communicate that the dietitian and nutrition manager should be copied on any updates and Ministrycommunications regarding the RAI-MDS 2.0 Project4. Access the Nutrition Care Resource Guide from the Project portal- Print the presentation from the RAI-MDS 2.0 Nutrition Care Resource Guide Part IV (RAI-MDS 2.0Introduction)- Ensure all nutrition care team members review the presentationFor Information: 416.327.7625 14ltchrai@ontario.ca14

CHAPTER 2: RAI-MDS 2.0 AssessmentCHAPTER 2: RAI-MDS 2.0 Assessment....................................................1Selected Coding Sections of RAI-MDS 2.0 ..............................................2Overview of Assessment Timelines ......................................................10RAI-MDS 2.0 Nutrition Assessment Process for:...................................16Admission ...........................................................................................................................................................16RAI-MDS 2.0 Nutrition Quarterly, Significant Change or Annual Assessment Process......................................19Scheduler for Part Time Team Member.................................................21Preparing to Code Checklist..................................................................22Coding Software Orientation Checklist.................................................23Recommended Tools (Optional) ............................................................24Admission Nutrition Assessment Worksheet (optional) For Beginning RAI-MDS 2.0 User ................................24Admission Nutrition Assessment Worksheet (optional) For Experienced RAI-MDS 2.0 User ............................28Nutrition/Hydration Risk Identification Tool - Optional ........................................................................................32For Information: 416.327.7625 1ltchrai@ontario.ca

Selected Coding Sections of RAI-MDS 2.0INTRODUCTION The most common RAI-MDS 2.0 section that the nutrition care team is responsible for is all or part of Section K:Oral/Nutritional StatusOther sections that the nutrition care team may be responsible for and/or contribute to are:- J1d: Insufficient Fluid- M5d: Nutrition or Hydration to Manage Skin ProblemsIndividual home’s policy will determine who completes each section of the RAI-MDS 2.0 assessment. It isimportant that the registered dietitian and nutrition manager are familiar with all nutrition care related codingregardless of whether they complete the coding or notThe nutrition care team is responsible for verifying coding accuracy before completing RAPs and care planningGETTING READY FOR CODING It is important to know the following for each RAI-MDS 2.0 assessment item:- coding intent and the assessment period (e.g. last 7 days, 14 days, 30 days)- coding choices and definition- approach/process for gathering the coding informationK1: ORAL PROBLEMSINTENT:To record any oral problems present in the last 7 days.CODING CHOICES AND DEFINITIONS:a. Chewing problem: Inability to chew food easily and without pain or difficulties, regardless of cause (e.g.resident uses ill-fitting dentures, or has a neurologically impaired chewing mechanism, or a painful tooth).b. Swallowing problem (Dysphagia): Clinical manifestations include frequent choking and coughing wheneating or drinking, holding food in mouth for prolonged periods of time, or excessive drooling.c. Mouth pain: Any pain or discomfort associated with any part of the mouth, regardless of cause.d. None of the abovePROCESS: Ask the resident/family about difficulties in the areas of chewing, swallowing and mouth pain Observe the resident during meals Inspect the mouth for abnormalities that could contribute to the above problemsREMEMBER:Continue to code chewing and swallowing problems even when compensatory strategies have been successfullyintroduced, but the resident remains unable to chew all types of foods and liquidsFor Information: 416.327.7625 2ltchrai@ontario.ca2

K2: HEIGHT AND WEIGHTINTENT:To record a current height and weight in order to monitor nutrition and hydration status over time and to provide amechanism for monitoring stability of weight over time.CODING DEFINITIONS:K2a. Height:Measure height in centimeters on admission and annually. Round the number to the nearest whole centimeter. Ifresident refuses to have height measured, code “001”. If resident is palliative, and cannot be measured, code “248”K2b. Weight:Measure weight in kilograms based on the last 30 days and round the number to one decimal place, e.g. 64.6 kg. Ifresident refuses to be weighed, code “0001”. If resident is palliative, and cannot be weighed, code “9999”PROCESS:K2a. Height: Check the clinical records. If the last height recorded was more than one year ago, measure the resident again For a resident who cannot stand, height can be assessed using a tape measure and measuring the body insections Arm span, knee height and ulna length measure can be usedK2b. Weight: Check the clinical records If last weight was taken more than one month ago or weight was not available, weigh the resident again andrecord most recent weight.K3: WEIGHT CHANGEINTENT: To record variations in the resident’s weight over timeCODING CHOICES AND DEFINITIONS:a. Weight loss in percentages (e.g. 5% or more in last 30 days or 10% or more in last 180 days)b. Weight gain in percentages (e.g. 5% or more in last 30 days or 10% or more in last 180 days)PROCESS: For new admissions ask resident or family about weight changes over the last 30 and 180 days Consult physician, transfer documentation and compare with admission weight. Calculate weight loss or gain inpercentages during the specified time periods For current residents, review clinical record and compare weight with weights of 30 and 180 days ago. Calculateweight loss or gain in percentages during the specified time periods Code 0 for “No” and 1 for “Yes”. If on admission there is no weight to compare to, code “9” for UnknownFor Information: 416.327.7625 3ltchrai@ontario.ca3

WEIGHT CHANGE CALCULATION EXAMPLE:Current Weight: 50 kgWeight 30 days ago: 53 kgWeight Change: 53 kg - 50 kg = 3 kg loss in weightPercentage of Weight Change: (3 kg / 53 kg) x 100 = 5.6% loss in weightK3a would be coded as “yes”K4: NUTRITIONAL PROBLEMSINTENT:To identify specific problems, conditions, and risk factors for functional decline present in the last 7 days that affect orcould affect the resident’s health or functional status. Such problems can often be reversed and the resident canimprove.CODING CHOICES AND DEFINITIONS:a. Complains about the taste of many foods: May be attributed to health conditions, medications orculturally basedb. Regular or repetitive complaints of hunger: On most days (at least 2 out of 3), the resident asks for morefood or repetitively complains of feeling hungry even after eating a mealc. Leaves 25% or more of food uneaten at most meals: Eats less than 75% of food at least 2 out of 3 mealsper day. (Assuming the appropriate serving size is provided)d. None of the AbovePROCESS: Consult resident’s records (including current nursing plan of care), dietary/fluid intake sheets, dietary progressnotes/assessments Observe the resident at meal times Interview resident/family and direct-care staffK4: WEIGHT CHANGEINTENT: To record all nutritional approaches used for a resident during the last 7 daysCODING CHOICES AND DEFINITIONS:a. Parenteral/IV: Intravenous fluids or hyperalimentation given continuously or intermittently including totalparenteral nutrition (TPN), intravenous therapy (IV) to keep vein open via any IV route. It does not includeadministration of IV medications which would be captured in P1c, “Special Treatments and Procedures”b. Feeding tube: Presence of any type of tube that can deliver food/nutritional substances/fluids/medicationsdirectly into the GI system, e.g. nasogastric tube and jejunum tubec. Mechanically altered diet: A diet specifically prepared to alter consistency of food in order to facilitate oralintake. Examples include soft solids, pureed food and ground meat. Diets for residents who can only takeliquids that have been thickened to prevent choking are also included.d. Syringe (oral feeding): Use of syringe to deliver liquid or pureed nourishment directly into the mouthFor Information: 416.327.7625 4ltchrai@ontario.ca4

e. Therapeutic diet: A diet ordered to manage problematic health conditions. For example, weight reducing,low salt, low fat, no added sugar, diabetic, renal, high energy and high protein, fluid restrictions andsupplements during mealsf. Dietary supplements between meals: Any type of dietary supplement provided between scheduled mealslike a high protein/calorie shake at 3:00 p.m. Do not include snacks that all residents receive as part of theunit’s daily routine.g. Plate guard, stabilized built-up utensils, etc. Any type of specialized, altered or adaptive equipment usedto facilitate the resident’s involvement in self-performance of eatingh. On planned weight change program: Resident is receiving a program of which the documented purposeand goal are to facilitate weight gain or loss, e.g. double portions, high calorie supplements, or reducedcaloriesi. None of the AbovePROCESS: Consult medical record, dietary progress notes and assessmentsK6: PARENTAL AND ENTERNAL INTAKEINTENT: To record the proportion of calories (K6a) and the average fluid intake (K6b) actually received (not ordered)through parenteral or tube feeding in the last 7 days.CODING CHOICES AND DEFINITIONS:a. Code the proportion of total calories the resident received through parenteral or tube feeding in the last 7daysIf resident has IV and /or tube feeding and took nothing by mouth or only sips of fluids thenK6a = “4”, 76% to 100% by parenteral or enteral routeb. Code the average fluid intake per day by IV or tube in the last 7 days.PROCESS FOR CODING K6A (TOTAL CALORIES): Review intake records If resident took no food or fluids by mouth, or took just sips of fluid, stop here and code “4” (76% - 100%) If the resident had more substantial oral intake than this, the dietitian will derive a calorie count received fromparenteral or tube feedingsFor Information: 416.327.7625 5ltchrai@ontario.ca5

EXAMPLE:Step 1: Calculate Total CaloriesDay Oral (Calorie) IV/Feeding Tube (Calorie)Sun. 500 2000Mon. 250 2250Tues. 250 2250Wed. 350 2250Thurs. 500 2000Fri. 800 1800Sat. 800 18007-Day Total 3450 14350Step 2: Total Calories = 3450 (oral) + 14350 (IV/Feeding Tube) = 17800Step 3: Calculate percentage of total calories by IV / feeding tube = 14350/17800 = 0.806 To get a percentage multiply by 100 0.806 x 100 = 80.6 %Step 4: Code “4” for 76% to 100%PROCESS FOR CODING K6B (AVERAGE FLUID INTAKE): Review intake and output records for last 7 days Calculate the actual amount of fluid received. Include free water in tube feeding and IV piggybacks. Do notinclude heparin lock flushes Calculate over the last 7 days even if the resident did not receive fluids on all 7 days Divide the week’s total fluid intake via IV/tube feeding by 7 days in all casesFor Information: 416.327.7625 6ltchrai@ontario.ca6

EXAMPLE:DayDaily Fluid IntakeSun.Mon.Tues.Wed.Thurs.Fri.Sat.7-Day Total1250 cc725 cc925 cc1200 cc1200 cc1200 cc1000 cc7550 ccTotal = 7550 cc / 7 days = 1078.6 cc per dayCode “3” for 1001-1500 cc per dayJ1d: INSUFFICIENT FLUIDINTENT:To record specific problems or symptoms that affects or could affect the resident’s health or functional status.CODING DEFINITION:Insufficient fluid: Did not consume all or almost all liquids provided during the last 3 days. Liquids include water,juices, coffee, gelatines and soups.PROCESS: Interview and observe resident Review clinical records including plan of care and intake records Consult front line staff and familyM5d: NUTRITION OR HYDRATION INTERVENTIONINTENT:To document any nutrition or hydration intervention to manage skin problemsCODING DEFINITIONS: Nutrition or hydration interventions include dietary measures received by the resident for the purpose ofpreventing or treating specific skin conditionsFor Information: 416.327.7625 7ltchrai@ontario.ca7

Examples include wheat-free diet to prevent allergic dermatitis, high calorie diet with added supplements toprevent skin breakdown and high protein supplements for wound healingPROCESS: Review resident’s clinical record including intake records. Interview the resident and care team.Note: Individual home’s policy will determine if the dietitian or nutrition manger completes this section of the RAI-MDS 2.0 assessment.R2b: ASSESSMENT INFORMATIONINTENT:To record staff signatures and titles of persons completing sections of the assessment.PROCESS: Each staff member who completes any section of the RAI-MDS 2.0 must sign, indicate title, sections he/shecompleted and date the assessment was completed The Assessment Coordinator must not sign the assessment as complete until all other assessors have signedtheir portions as complete.OTHER RELEVANT RAI-MDS SECTIONSTo obtain a complete clinical picture of a resident it is important to review all the completed sections of the RAI-MDS2.0 focusing particularly on the following RAI-MDS 2.0 sections:B4Cognitive Skills for Daily DecisionMakingC6Ability to understand othersD2 Visual limitations/Difficulties E4d Socially inappropriate or disruptive behaviourG1h Ability to feed self H2 Bowel Elimination PatternI Disease Diagnosis J J1: problem conditionJ2: pain symptomsJ5: stability of conditionsL1 Oral Status M1 UlcersO4 Medications P1A Special Treatments i.e. dialysisP9Abnormal LabsFor Information: 416.327.7625 8ltchrai@ontario.ca8

COMMON CAUSES OF CODING ERRORS Misinterpreting coding rules: not understanding intent, definitions and processes for coding Not using the correct assessment dates Inconsistent data between sources Not capturing the resident’s activities throughout the 3 shifts per day during the full look-back period Missing items Auto-populating by software Doing a paper review only, not interviewing resident/family or staff Home processes e.g. interdisciplinary team documentation is not organized and centralized, making it difficult todo RAI-MDS 2.0 coding; lack staff input from evening and night shiftsRAI-MDS 2.0 SECTIONS WITH FREQUENT CODING ERRORSBased on Data Accuracy Review Team (DART) in OntarioRAI-MDS 2.0SectionIDiseaseDiagnosesJHealthConditionsSection ItemIpp - AllergiesI1 - DiseasesJ1 - Problem ConditionsJ2a - PainJ5 - Stability of ConditionsPotential Reason for Errors• Not including food allergies when codingallergies• Coding diagnoses that are not current• Not coding all applicable diagnoses• Failing to code items in this section• Not capturing all pain• Not coding diseases or health conditions that areacute, unstable or deterioratingKK5e - Therapeutic DietOral/ NutritionalStatusK2 - Height• Not including diets to manage problematic healthconditions or special diets to manage foodallergies and supplements during meals• Not updating height annuallySTRATEGIES TO IMPROVE RAI-MDS 2.0 ACCURACYRAI-MDS 2.0 assessors should: Consistently use the CIHI RAI-MDS 2.0 User’s Manual (September 2010) to understand intent, definitions andprocess Be familiar with common coding errors and the most common causes of those errors Review e-Query data base from CIHI website Allow sufficient time for assessors to learn coding Identify facility/unit mentors that can assist as “buddies” for new coders Use good assessment practice in completing RAI-MDS 2.0 assessment: observing the resident, interviewingthe resident, staff and significant others and reviewing clinical records carefully (e.g. MARs, TARs, CCAC,consultations, documentation from outside appointments or hospital visits) Ensure the clinical data covers the correct timeframe (e.g. 7 days, 30 days etc.) Collaborate with interdisciplinary team members to ensure charting accurately reflects the resident across the 3shifts and across disciplines Review the previous RAI-MDS 2.0 assessmentFor Information: 416.327.7625 9ltchrai@ontario.ca9

Overview of Assessment TimelinesOBSERVATION PERIOD• Each RAI-MDS 2.0 assessment has an observation period• During the observation period, the interdisciplinary team members gather information for completion of theassessment• Observation periods are clearly identified on the RAI-MDS 2.0 assessment. Most are 7 days and some havelonger or shorter observation periods• For example, the look back period for K1 and K4-6 is 7 days; the look back period for K2b is the last 30 daysASSESSMENT REFERENCE DATE• The last day of the Observation Period is called the Assessment Reference Date (ARD)• Home’s RAI Coordinator will provide the team with the ARD for each resident’s assessment• After the ARD has passed, the team can begin the RAI-MDS 2.0 assessment (all of the IDT are required to usethe same ARD)TYPES OF ASSESSMENTS1. Admission Full Assessment2. Quarterly Assessment3. Annual Full Assessment4. Significant Change in Status Full Assessment1. ADMISSION FULL ASSESSMENT TIMELINETHE ADMISSION FULL ASSESSMENT FOR A NEW RESIDENT MUST BE COMPLETED BY THE 14 TH CALENDAR DAY FOLLOWINGADMISSION TO THE FACILITY IF THIS IS THE RESIDENT’S FIRST STAY IN THE FACILITY.The day of admission is counted as day 0 and the 14 day calculation includes weekends.RAI-MDS 2.0 assessment must be entered into the computer software between day 8 to day 14 of admission(assuming an ARD of day 7).PROJECT RECOMMENDATIONS:• Input RAI-MDS 2.0 coding between Day 8 to 10 and;• Complete RAPs documentation between day 11 to 14For Information: 416.327.7625 10ltchrai@ontario.ca10

RAI-MDS 2.0 TimelinesAdmission Full AssessmentMaximum 7 days Maximum 7 days Maximum 7 daysAdmissionDAY 0 DAY 7 DAY 14DAY 2124-HourCare Plan7-dayObservation Period1. Complete MDSAssessmentComplete Care Plan2. Generate RAPs3. Complete RAPAssessmentSummariesARDR2bARD must be within 14 daysof admission. The Projectrecommends ARD on MDS day 7.Vb1 + Vb2Vb3 + Vb4ADMISSION FULL ASSESSMENT TIMELINE EXAMPLEDateMay1May2May3May4May5May6May7May8May9May10May11May12May13May14May15Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed ThuMDS Day 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14Observation PeriodAssessmentReferenceDate (ARD)Assessmentsigned ascomplete (R2b)For Information: 416.327.7625 11ltchrai@ontario.ca11

2. QUARTERLY ASSESSMENT TIMELINEThe Quarterly Assessment must be completed on a quarterly basis between full assessments and within 92 daysfollowing the last Full or Quarterly Assessment.Quarterly assessment can be completed earlier than 92 days (every 3 months) but not later.PROJECT RECOMMENDATIONS:• Input RAI-MDS 2.0 coding between Day 8 to 10 and• Complete RAPs documentation between day 11 to 14QUARTERLY ASSESSMENT TIMELINEMaximum 7 days Maximum 7 days Maximum 7 daysDAY 0 DAY 7DAY 14DAY 217-dayObservation Period1. Complete MDSAssessmentComplete Care Plan2. Generate RAPs3. Complete RAPAssessmentSummariesARDWithin 92 days of ARD of lastFull or Quarterly AssessmentR2bVb1 + Vb2Vb3 + Vb43. ANNUAL FULL ASSESSMENT TIMELINEANNUAL FULL ASSESSMENTS MUST BE COMPLETED WITHIN 366 DAYS OF THE ASSESSMENT REFERENCE DATE (A3) OFTHE LAST FULL ASSESSMENT.Annual Assessment can also be completed earlier than 366 days but not later.PROJECT RECOMMENDATIONS:• Input RAI-MDS 2.0 coding between Day 8 to 10 and• Complete RAPs documentation between day 11 to 14For Information: 416.327.7625 12ltchrai@ontario.ca12

ANNUAL FULL ASSESSMENT TIMELINEMaximum 7 days Maximum 7 days Maximum 7 daysDAY 0 DAY 7 DAY 14DAY 217-dayObservation Period1. Complete MDSAssessmentComplete Care Plan2. Generate RAPs3. Complete RAPAssessmentSummariesARDWithin 366 days of ARD of lastFull Assessment.R2bVb1 + Vb2Vb3 + Vb44. SIGNIFICANT CHANGE IN STATUS FULL ASSESSMENT TIMELINEAny significant change in resident’s condition, either decline or improvement, shall be reassessed by theinterdisciplinary care team using the RAI-MDS 2.0 Full Assessment within 14 days of the determination in the changein status.Completing this assessment would reset the schedule of the next assessment.A significant change is defined as a major change in the resident’s status that: is not self limiting impacts on more than one area of the resident’s health status; and requires interdisciplinary review and/or revision of the plan of care.Home RAI Coordinator will inform the care team of significant change in health status assessment.For Information: 416.327.7625 13ltchrai@ontario.ca13

TIMELINE FOR SIGNIFICANT CHANGE IN STATUS FULL ASSESSMENTMaximum 7 days Maximum 7 days Maximum 7 daysDAY 0 DAY 7 DAY 14DAY 217-dayObservation Period1. Complete MDSAssessmentComplete Care Plan2. Generate RAPs3. Complete RAPAssessmentSummariesARDARD must be within 14 days ofdetermining that a significantchange has occurred. (Projectrecommends ARD of day 7.)R2bVb1 + Vb2Vb3 + Vb4EXAMPLE OF ASSESSMENT TIMELINESFor Information: 416.327.7625 14ltchrai@ontario.ca14

NUTRITION CARE TEAM RESPONSIBILITY• Reviews the RAI-MDS 2.0 scheduler at least weekly - know which residents are due for assessments and theirARDs• During the 7-day observation period, nutrition care team gathers information by:− Observing resident during meal time− Interviewing resident, significant others and staff− Reviewing all relevant documentation• Communicates to back-up assessor and the RAI Coordinator immediately if unable to complete assessmentwithin required timelines• Completes or reviews all assessments according to timelinesFor Information: 416.327.7625 15ltchrai@ontario.ca15

RAI-MDS 2.0 Nutrition Assessment Process for:AdmissionFor Information: 416.327.7625 16ltchrai@ontario.ca

RAI-MDS 2.0TimelineRecommendedProcess(adapt to meethome policyrequirements)ToolDay 0(Day of Admission)Day 1 to Day 7 (ARD)(7 days)For Information: 416.327.7625 17ltchrai@ontario.ca17Day 8 to Day 14(7 Days)First Day of New Admission Observational Period RAI-MDS 2.0 AssessmentRAPs DocumentationOn admission, Nursing: Dietitian, Nutrition Manager or• completes 24 hour care plan Nursing:• obtains diet order from • collects information for RAI-MDSphysician2.0 coding• notifies nutrition manager • interviews resident, familyand dietitian of crisismembers and care providers asplacement and priorityrequiredresidents who are on enteral • reviews documentation, includingfeeding, dialysis, have celiac physician, lab values, 24 hourdisease or swallowingnursing assessment and care plan,issuesinformation from CCAC, progress• notifies kitchenette, nursing notes, transfer notes, intakestaff and nutritionrecord, flow sheet and othermanager/food service • observes the resident at mealsdepartment of newand snacksadmission and diet orderincluding allergies• Home specific diet orderform• Dietitian Referral Form(Optional)Dietitian:• follows up regarding priorityresidents• starts Admission NutritionAssessment Worksheet (optional)• Admission Nutrition AssessmentWorksheet (optional)Dietitian:• completes RAI-MDS 2.0 coding• completes Admission Nutrition AssessmentWorksheet (optional)• reviews Section V and triggers for each nutritionalRAP• reviews RAI-MDS 2.0 full assessment to identifynon-triggered clinical problems related to nutritioncare• completes RAPs and non-triggered clinicalproblems assessment summaries following the 5step critical analysis• assigns nutrition risk level as per home’s policy*Depending on the policy of the home, in theabsence of dietitian, nursing and nutrition managerwill work collaboratively to complete the aboveactivities.Project Recommendations:• input RAI-MDS 2.0 coding between Day 8 to 10• complete RAPS documentation between Day 11 to14• RAI-MDS 2.0 Full Assessment• Section V RAP Summary• Nutrition/Hydration Risk Identification Tool(Optional)Day 15 to Day 21( 7 days)Care PlanningDietitian:• completesadmissionnutrition care planRecommendation:• care plan can becompleted earlybut not later than21 days17

Day 0 First Day of New Admission On Admission, Nursing:• Completes 24 hour care plan• Obtains diet order from physician• Notifies nutrition manager and dietitian of crisis placement and priority residents• notifies kitchenette, nursing staff and nutrition manager/food service department ofnew admission and diet order including allergiesDay 1-7 Observational Period Dietitian, Nutrition Manager or Nursing:• collects information for RAI-MDS 2.0 coding• interviews resident, family members and care providers as required• reviews documentation• observes the resident at meals and snacksDietitian:• follows up regarding priority residentsstarts Admission Nutrition Assessment Worksheet (optional)Day 8-14RAI-MDS 2.0 Admission Assessment andRAPs DocumentationDietitian:• Completes RAI-MDS 2.0 coding• Completes Admission Nutrition Assessment Worksheet (optional)• Assigns nutritional risk level as per home policy• Reviews Section V and triggers for each nutritional RAP• Reviews RAI-MDS 2.0 full assessment to identify non-triggered clinical problemsrelated to nutrition care• Completes RAPs and non-triggered clinical problems assessment summariesfollowing the 5 step critical analysisProject Recommendations:• input RAI-MDS 2.0 coding between Day 8 to 10• complete RAPS documentation between Day 11 to 14Day 15-21 Care Planning Dietitian Completes admission nutrition care planRecommendation: care plan can be completed early but not later than 21 days ON ADMISSIONFor Information: 416.327.7625 18ltchrai@ontario.ca1818

RAI-MDS 2.0 Nutrition Quarterly, Significant Change or Annual AssessmentProcessRAI-MDS 2.0TimelineRecommendedProcess(adapt to meethome policyrequirements)Day 1 to Day 7 (ARD)(7 days)Observational PeriodDietitian, Nutrition Manager or Nursing:• collects information for RAI-MDS 2.0coding• interviews resident, family members,care providers as required• observes the resident at meals• reviews relevant information includingprogress notes, lab results, flow sheet,weight record, intake and output etc.Day 8 to Day 14(7 Days)RAI-MDS 2.0 AssessmentRAPs DocumentationDietitian, Nutrition Manager or Nursing:• completes RAI-MDS 2.0 coding according to thehome’s policy, RAPs and Plan of CareNote: Home using the RAI-MDS 2.0 QuarterlyAssessment:Sections K1.c, K4.a, K4.b, K5.c, and K5.e are notincluded in Quarterly assessments.Dietitian and/or Nutrition Manager:• reviews Section V and triggers for each nutrition RAP• reviews previous RAPs and non-triggered clinicalproblems• identifies any new non-triggered clinical problemsrelated to nutrition care• completes RAPs and non-triggered clinical problemsassessment summaries following the 5 step criticalanalysis• reassesses nutrition risk level if applicableDay 15 to Day 21( 7 days)Care PlanningDietitian, Nutrition Manager or Nursing incollaboration with the interdisciplinary teammembers:• reviews and revises nutrition care plan asneeded according to RAPs and non RAPsdocumentation(Depending on the home’s policy, NutritionManager completes care plan for low andmoderate risk residents and Dietitiancompletes high risk residents)Tool • RAI-MDS 2.0 Full or Quarterly Assessment Form• Nutrition/Hydration Risk Identification Tool (Optional)For Information: 416.327.7625 19ltchrai@ontario.ca1919

RAI-MDS 2.0 Nutrition Quarterly, Significant Change or Annual Assessment ProcessDay 1-7 Observational Period Dietitian, Nutrition Manager or Nursing:• collects information for RAI-MDS 2.0 coding• interviews resident, family members, care providers as required• observes the resident at meals• reviews relevant information including progress notes, lab results, flow sheet,weight record, intake and output etc.Day 8-14RAI-MDS 2.0 Assessment andRAPs DocumentationDietitian, Nutrition Manager or Nursing:• completes RAI-MDS 2.0 coding, RAPs and Plan of Care according to thehome’s policy.Note: Home using the RAI-MDS 2.0 Quarterly Assessment:Sections K1.c, K4.a, K4.b, K5.c, and K5.e are not included in Quarterlyassessments.Dietitian and/or Nutrition Manager:• reviews Section V and triggers for each nutrition RAP• reviews previous RAPs and non-triggered clinical problems• identifies any new non-triggered clinical problems related to nutrition care• completes RAPs and non-triggered clinical problems assessment summariesfollowing the 5 step critical analysis• reassesses nutrition risk level if applicableDay 15-21 Care Planning Dietitian, Nutrition Manager or Nursing in collaboration with theinterdisciplinary team members:• reviews and revises nutrition care plan as needed according to RAPs andnon RAPs documentation(Depending on the home’s policy, Nutrition Manager completes care plan forlow and moderate risk residents and Dietitian completes high risk residents)For Information: 416.327.7625 20ltchrai@ontario.ca2020

Scheduler for Part Time Team MemberThe following are recommended strategies for the RAI Coordinator to follow while supporting part time nutrition care team members with theRAI-MDS 2.0 assessment and care planning process.1. Set ‘Assessment Reference Date (ARD)’ or the last day of the observation period prior to the scheduled workday of the part time staff.For example, if the part time dietitian works only Wednesday, set the ARD on Monday or Tuesday. This way he/she can start orcontribute to the coding assessment when in the facility. If this is not possible, nursing can complete the RAI-MDS 2.0 assessment for other disciplines. Depending on the home’s policy,nursing may make referral to the part time dietitian to review coding.2. Sign the R2b to indicate that assessment is complete prior to the scheduled workday of the part time staff.For example, if the part time dietitian works only Thursday, sign the R2b on Tuesday or Wednesday. This way he/she cancomplete or contribute to the RAPs assessment summary documentation and care planning when in the facility.If this is not possible, nursing can complete the RAPs documentation and the plan of care. Depending on the home’s policy,nursing may make referral to the part time dietitian to review the RAPs documentation and the plan of care.The following diagram illustrates how to set the ARD to facilitate the dietitian involvement in the RAI-MDS 2.0 assessment and care planningprocess.Scenario Example 1 Part time dietitian works one day a week on Wednesday.In this situation, the home will decide whether the dietitian will contribute to the coding or RAPs documentation and care planning. It is highlyrecommended that the dietitian contributes to RAP documentation and care planning. If the dietitian discovers coding errors during the RAPanalysis, he/she can refer to the RAI Coordinator to make coding correction and then re-trigger the RAP.Day7ThursARDRD inRD inFacilityFacility8 9 10 11 12 13 14 15 16 17 18 19 20 21Fri Sat Sun Mon Tues Wed Thurs Fri Sat Sun Mon Tues Wed ThursRAI-MDS2.0AssessmentCompletionSigned R2bRAPsCompletionSignedVB2Plan ofCareCompletionSignedVB4Scenario Example 2 Part time dietitian works 2 days a week on Tuesday and ThursdayRD inFacilityRD inFacilityRD inFacilityRD inFacilityDay 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21Sun Mon Tues Wed Thurs Fri Sat Sun Mon Tues Wed Thurs Fri Sat SunARDRAI-MDS2.0AssessmentCompletionRAPsCompletionPlan ofCareCompletionSigned R2bSignedVB2For Information: 416.327.7625 21ltchrai@ontario.caSignedVB4

Preparing to Code ChecklistThe following checklist summarizes the important tasks for the nutrition care team to review and/or use during RAI-MDS 2.0 coding1. With the dietary team members:- Discuss and establish the role and responsibilities of the dietitian and nutrition managerrelated to coding- Discuss coding workload distribution within the department (e.g. who completes newadmission, hospital return residents, significant change in health status residents etc.)2. Meet with RAI Coordinator to:- identify coding backup for the dietitian and nutrition manager, if they participate incoding- discuss where, how and when to review the nutrition related coding for accuracy, ifnutrition care team is not directly inputting coding- set-up a monthly meeting for update and feedback from RAI coordinator- discuss where and how to access/communicate information regarding residentadmission, transfer and discharge and significant change in status assessment- review where and how to access the 7-day observational flow sheet- identify the posting location or method of communicating the RAI-MDS 2.0 Schedule,also known as the Assessment Planner- review current tools or forms to aid the collection of information for coding during theobservational period (e.g. PSW observational flow sheet)- discuss coding errors and correction processes- review dietitian referral process to ensure timeliness3. Establish the training date and time with the RAI Coordinator for coding and RAI-MDS 2.0software.4. Determine who, in the food service department, will attend the training.5. Access and print the coding chapter of the Nutrition Care Resource Guide found on thePortal6. Attend training for:- Coding- RAI-MDS 2.0 software (don’t forget to take the Coding Software Orientation Checklist totraining)7. Ensure nutrition care team members review the coding chapter from the Nutrition CareResource Guide.8. During the early coding learning phase, find a coding buddy together with the RAICoordinator. The coding buddy can be the RN or RPN.9. Arrange the time for RAI Coordinator to audit for coding accuracy.10. Review the RAI-MDS 2.0 schedule on a weekly basis.11. Review CIHI User’s Manual (September 2010) as a reference.12. With the dietary team members:- Discuss and establish the role and responsibilities of the dietitian and nutrition managerrelated to coding- Discuss coding workload distribution within the department (e.g. who completes newadmission, hospital return residents, significant change in health status residents etc.)For Information: 416.327.7625 22ltchrai@ontario.ca22

Coding Software Orientation ChecklistThis checklist will serve as a guide for dietitians and nutrition managers in their coding software orientation. Pleasefeel free to add other skill requirements that are specific to your software. At the end of your software orientation, youshould be competent in performing the following computer tasks.1.2.3.4.5.6.7.8.9.10.11.12.13.Skills Checklist Notes/Comments CheckCodingLog in and open the RAI-MDS 2.0 assessment folderFind resident(s) for RAI-MDS 2.0 assessmentLocate the RAI-MDS 2.0 assessment forms, including RAI-MDS 2.0 full assessment, quarterly assessment, admissionbackground form, discharge and re-entry formsOpen and close RAI-MDS 2.0 assessment formCreate new RAI-MDS 2.0 assessment (if appropriate) andwork on an existing full assessmentNavigate through the sections of the RAI-MDS 2.0assessment with special attention to Sections K, M, J, R and VMaximize and minimize the RAI-MDS 2.0 assessment formSave and close sections of the RAI-MDS 2.0 assessmentwhile navigatingView previous quarterly assessments going forwardEnable different options in the software (i.e. auto fill, ability tomake notes while completing the assessment, etc.)Understand how to read the software audits and makecorrections (if appropriate)Complete Section RPrint the RAI-MDS 2.0 assessment formFor Information: 416.327.7625 23ltchrai@ontario.ca23

Recommended Tools (Optional)Admission Nutrition Assessment Worksheet (optional) ForBeginning RAI-MDS 2.0 UserThe College of Dietitians of Ontario “Record Keeping Guidelines for Registered Dietitians 2004” indicates thatdietitians do not have to duplicate background health information that has been provided by another practitioner;however, a reference to the appropriate section(s) that the dietitian has reviewed must be documented (RecordKeeping Guidelines for Registered Dietitians 2004, Section d(e)).The purpose of this Admission Nutrition Assessment Worksheet is to assist new RAI-MDS 2.0 Users with:Summarizing their RAI-MDS 2.0 assessment reviewAddressing areas of assessment that are not covered by the RAI-MDS 2.0 full assessment (as identified in theprevious work of the ‘Part A Nutritional Care Resource Guide’)Identifying non-triggered clinical problems for admission plan of careThe use of this tool is optional. It is intended to be completed on admission only. Dietitian can customize the tool tomeet his/her admission assessment needs.For Information: 416.327.7625 24ltchrai@ontario.ca24

Admission Nutrition Assessment Worksheet - For Beginners (optional)Resident’s Name: Room #: DOA:Language Spoken:Religious/Cultural Needs:Anthropometric Measures and Physical observationAdmission Height (cm): RAI-MDS 2.0: K2 Admission Weight (kg): RAI-MDS 2.0: K2 Usual Body Weight (kg):‘Average’ Weight for Ht/Age/Sex (kg): Resident’s Goal Weight (kg): BMI:Weight HistoryPhysical signs of malnutrition RAI-MDS 2.0: Sections H, K, L, I, M, PMedical Information:Pertinent Diagnosis and Surgical History RAI-MDS 2.0: Sections B, C, D, E, G, I, J, M, O PRAI-MDS 2.0 Output Score:CPS: DRS: CHESS: Pain: ISE: ADL (Long):Medications with Nutritional Implications (including vitamins/minerals): RAI-MDS 2.0: Sections O and U (optional)Laboratory Data: RAI-MDS 2.0: P9Gastrointestinal RAI-MDS 2.0: Sections H, I, J, OGastrointestinal Problem:Managed By:Comment:Skin RAI-MDS 2.0: Sections M, PNutrition Related Skin Problem:Managed By:Comment:Chewing RAI-MDS 2.0: Sections I, J, K, L P No  Yes, Reason: Managed By:Comment:Swallowing RAI-MDS 2.0: Sections I, J, K, L P No  Yes, Reason: Managed By:Comment:Oral RAI-MDS 2.0: Section L No  Yes, Reason: Managed By:Comment (including last dental visit):For Information: 416.327.7625 25ltchrai@ontario.ca25

Sensory Deficit Affecting Nutritional Intake RAI-MDS 2.0: Sections B, C, D No  Yes, Reason: Managed By:Comment:Diet Information: RAI-MDS 2.0: Sections A10f, H, I, J K, MCurrent Diet/Enteral Feeding Order:Diet Texture:Food Allergies/Intolerances and Side Effects:Fluid Consistency:Meal Observation:Eating Ability: RAI-MDS 2.0: Section G, P Independent  Extensive Assistance  Supervision (encouragement and cueing) Limited Assistance  Total DependenceEating Behaviors: RAI-MDS 2.0: Sections EAssistive Feeding Devices: RAI-MDS 2.0: Section KDiet History: RAI-MDS 2.0: Sections AC1i-k, J, KSpecial Diet Recommended Previously: Yes  No Reason:Did you follow it?  Yes  No, Reason:Comment:Appetite History:  Good  Fair  PoorComment:Nutrition Supplements/Special Snacks: RAI-MDS 2.0:Section KType:Amount:Comment:Best Meal:  Breakfast  Lunch  DinnerComment:Food and Fluid Preferences: (state specific food and beverage preferences and dislikes) Vegetables  Fruits  Grain Products  Milk and Alternatives  Meat and Alternatives  Others:Comment:Food Intake:Average Reported Food Intake:  >75-100%  50-75%  1500cc/day  1000-1500cc/day  500-1000cc/day 

Summary of Nutrition Assessment Analysis:Nutrition Risk Status: High  Moderate  Low Related to:Non-Triggered Clinical Problem Identification: (It is important not to duplicate the documentation in the RAP assessment summary andcare plan. This section is to identify actual or potential non-triggered clinical problems only. Goals and care plan interventions are to be statedin the care plan document).For Information: 416.327.7625 27ltchrai@ontario.ca27

Admission Nutrition Assessment Worksheet (optional) For Experienced RAI-MDS 2.0UserThe College of Dietitians of Ontario “Record Keeping Guidelines for Registered Dietitians 2004” indicates that dietitians do not have to duplicate backgroundhealth information that has been provided by another practitioner; however, a reference to the appropriate section(s) that the dietitian has reviewed must bedocumented (Record Keeping Guidelines for Registered Dietitians 2004, Section d(e)).The purpose of this Admission Nutrition Assessment Worksheet is to assist experienced RAI-MDS 2.0 users with: Addressing areas of assessment that are not covered by the RAI-MDS 2.0 full assessment (as identified in the previous work of the ‘Part A Nutritional CareResource Guide’) Identifying non-triggered clinical problems for admission plan of careThe use of this tool is optional. It is intended to be completed on admission only. Dietitian can customize the tool to meet his/her admission assessment needs.For Information: 416.327.7625 28ltchrai@ontario.ca

Admission Nutrition Assessment Worksheet For Experienced User of RAI-MDS 2.0 (optional)Resident’s Name: Room #: DOA: Language Spoken:Essential Nutritional Assessment(RAI-MDS 2.0 Reference )Primary and secondary diagnosisPast medical and surgical historyMedication reviewRAI-MDS 2.0 Sections A, AB, B, C, D, E, G, I, J, M, O, PWeight historyUndesirable, unplanned weight changeRAI-MDS 2.0 Sections K, JNutrient-related systems reviewRAI-MDS 2.0 Sections AB, H, I, J, M, OAppetite and taste changeRAI-MDS 2.0 Sections J, KAreas for Further Considerations (identified in Part A Resource Guide)RAI-MDS 2.0 Output Score:CPS: DRS: CHESS: Pain:ISE: ADL (Long): Usual body weight (kg): ‘Average’ weight for Ht/Age/Sex (kg): Resident’s goal weight (kg):Medications with nutritional implications (including vitamins/minerals):Appetite history:  Good  Fair  PoorComment:Food intake:Average reported food intake:  >75-100%  50-75% 1500cc/day  1000-1500cc/day 500-1000cc/day 

Essential Nutritional Assessment Areas for Further Considerations (Part A Resource Guide) Non-Triggered Clinical Problem IdentificationGastrointestinal symptomsRAI-MDS 2.0 Sections H, I, J, OFood allergies/intolerances and side effects:Gastrointestinal problem is managed by:Chewing and swallowingRAI-MDS 2.0: Sections I, J, K, L PFeeding aids or assistanceRAI-MDS 2.0: Sections E, G, K, P2-37Chewing problem is managed by:Swallowing problem is managed by:Diet texture: Fluid consistency:Oral problem is managed by:Eating behaviors is managed by:Eating patternRAI-MDS 2.0: Sections AC1i-k, A10f, K5c,e fSensory deficit affecting nutritional intake:Nutrition supplements/special snacks:Type: Amount:Food and fluid preferences: (state specific food and beverage preferences) Vegetables  Fruits  Grain products  Milk and alternatives Meat and alternatives  Others:Best Meal:  Breakfast  Lunch  DinnerComment:For Information: 416.327.7625 30ltchrai@ontario.ca3030

Essential Nutritional Assessment Areas for Further Considerations (Part A Resource Guide) Non-Triggered Clinical Problem IdentificationDietary restrictions:Cultural/religious purposesOther dietary restrictionsRAI-MDS 2.0: Sections K5, I1Special diet recommended previously: Yes Reason:Did you follow it?  Yes  No, Reason:Religious/cultural needs: Self-imposed dietary restrictions:Food intolerance/hypersensitivitiesFood and fluid restrictions/dislikes (state specific food and beveragedislikes/restrictions) Vegetables  Fruits  Grain Products  Milk and Alternatives Meat and Alternatives  Others:Comment:Signs & symptoms of malnutritionnutrient deficiency RAI-MDS 2.0: Sections H, K, L, I, M, PNutrition related skin problem is managed by:Anthropometry and body composition:Body mass index (BMI) Frame sizeRAI-MDS 2.0: Section K2a-bBiochemical dataRAI-MDS 2.0 Section PEstimation of energy, protein, fluid, micronutrientsRAI-MDS 2.0: Sections B, K, M, I, J, H, N, GBMI:Laboratory Data:Energy (kcal)/day: Protein (g.)/day: Fluid (cc)/day:Other:For Information: 416.327.7625 31ltchrai@ontario.ca3131

Nutrition/Hydration Risk Identification Tool - OptionalResident Name: _______________________________________________Registered Dietitian to complete upon admission and whenever risk indicators change.HIGH NUTRITION / HYDRATION RISKSignificant weight change 5% - 1 mo., 7.5% - 3 mo., 10% -6 mo. (confirmed by reweigh) or 130% goal / usualbody weightSeverely underweight or BMI (< 18 in most elderlyindividuals)Severely overweight or BMI (> 32 in most elderlyindividuals)Recent changed appetite

Underweight or overweight but stable for 3 months ormorePoor appetite or changed appetite (intake 50 –75% foodsoffered) or history of using supplements / missing 1 wholefood groupPoor or changed fluid intake (50%) daily fluidrequirementFood allergies/food intolerances (including lactoseintolerance)New medical diagnosis requiring dietary restrictionDiagnosis of dementia – moderate affect on intakeHypertension, edemaControlled diabetes mellitus, renal disease or liver diseaseDysphagia – stableChronic constipation; frequent diarrhea; diverticular disease,changed bowel habitsPressure ulcer stage 1: very poor skin integrityReduced mobilityDifficulty feeding self / needs aides / intermittentassistance with feedingOther: (specify – see over)LOW NUTRITION / HYDRATION RISKNo significant weight change or weight stable or weight >90-110% goal / usual body weight or BMI 24-29Consumes > 75% from a variety of foods at most mealsConsumes >75% recommended daily fluid requirementRegular bowel functionEats independently or with minimal assistance / no feedingconcernMedical conditions stable per MD / minimal affect onintakeOther: (specify – see over)RISK LEVEL is assessed as:SIGNATUREDATEFor Information: 416.327.7625 33ltchrai@ontario.ca33

Assessing Nutrition / Hydration RiskThe RD is responsible for assessing and reassessing nutrition / hydration risk and assigning a risk level.High Nutrition / Hydration Risk – resident experiences numerous indicators that place them at a high level of risk formalnutrition/dehydration or has a diagnosis of malnutrition/dehydration or where nutrition intervention is a majorcomponent of the medical treatment. RD establishes nutrition care plan on admission and reassesses the residentfrequently (minimum quarterly), making changes to the care plan as required.Moderate Nutrition / Hydration Risk – resident experiences some risk factors related to malnutrition/dehydration orresidents whose diagnoses include nutrition intervention as a component of the medical treatment. RD establishesnutrition care plan on admission and reassesses the resident as required (delegating stable residents to be followedby NM/FSS as able - minimum quarterly) making changes to the care plan as required.Low Nutrition / Hydration Risk – resident is considered stable, has no significant weight concerns, no recent history ofneeding special diet or diagnosis of malnutrition; and does not have any current medical concerns that are likely toimpact on overall nutrition and hydration status or overall health outcomes. RD establishes nutrition care plan onadmission and delegates monitoring of residents to NM/FSS as able (minimum quarterly).Reassessing Risk Levels:RD reassesses the nutrition / hydration risk level using this tool whenever there has been a change inresident’s condition.Every three months, nutrition / hydration risk level is reviewed as part of the quarterly review; if resident’scondition is stable and indicators have remained stable, the nutrition / hydration risk level remains the same.A residents’ level of nutrition and hydration risk can change quickly – processes must be in place to inform the RDwhenever there are health changes/condition changes so that the nutrition risk level can be reassessed.Care plans must be updated whenever there is a change in nutrition / hydration risk level of a resident – care plansmust indicate current nutrition risk level.Other Factors Affecting Nutrition / Hydration Risk Level:Other indicators that need to be addressed when determining nutrition and hydration risk levels include - concernsfrom family/staff, recent surgery, infection, hospitalization, change in dental status, medical status, etc. – RDassesses all factors individually to determine their overall impact on nutrition and hydration status.Final Determination of Nutrition / Hydration Risk Level:Each indicator by itself does not necessarily determine risk level – risk of malnutrition and dehydration is multifactorial – RD must use professional judgment to determine final risk level and reevaluate risk levels wheneverresident status changes.Determining Healthy Weight Ranges:Healthy weight ranges:24-29 considered healthy weight for most elderlyBMI< 24 and > 29 may be associated with health problems in some elderlyReference: ADA/DC Manual of Clinical Dietetics 2000For Information: 416.327.7625 34ltchrai@ontario.ca34

For persons 65 years and older the “normal’ range may begin slightly above BMI 18.5 and extend into the“overweight” range.Reference: Health CanadaBMI must be taken into consideration with other weight parameters – height and weight tables for the elderly, weightchanges, usual versus ideal adult body weights, ethnic differencesUse of Usual Body Weight is the most important factor in assessing weight changesAdditional References:Average Weight (kg) for Height for Ages 65-94 years, Master, Laser, Beckman, 1960NHANES BMI men, NHANES BMI womenLTC Action Group, Dietitians of CanadaRevised June 2008Adapted from LTC Action Group, Dietitians of Canada 2008For Information: 416.327.7625 35ltchrai@ontario.ca35

CHAPTER 3: Resident Assessment Protocolsand Care PlanningCHAPTER 3: Resident Assessment Protocols and Care Planning ..........1RAPs and Care Planning ..........................................................................2Overview of RAPs and Care Planning Timelines ...................................12Preparing for RAPs and Care Planning Checklist..................................16RAPS and Care Planning Software Orientation Checklist ....................17The College of Dietitians of Ontario Documentation Requirementsadapted for Long-Term Care..................................................................18Nutrition Assessment and Care Planning Guidelines for RegisteredDietitian..................................................................................................22Sample RAPs Documentation - Essential Competencies for DieteticPractice..................................................................................................24Dietitian Referral....................................................................................29Dietitian Referral Orientation ..............................................................................................................................29Dietitian Referral Form (Optional).......................................................................................................................32Resident Assessment Protocol (RAP) Auditing Tool – Optional.........................................................................34For Information: 416.327.7625 1ltchrai@ontario.ca

RAPs and Care PlanningOVERVIEW• Getting started with Resident Assessment Protocol (RAP) implementation• RAPs and non-triggered clinical problems and benefits• RAP review process• Plan of care components and development• RAP Implementation StrategiesGETTING STARTED WITH RAPS IMPLEMENTATION• Review the RAPs and Plan of Care chapter in the RAI-MDS 2.0 Nutrition Care Resource Guide• Implement the “Preparing for RAPs and Care Planning Checklist” in the resource guideSELECTED REFERENCE• CIHI RAI-MDS 2.0 User’s Manual (2005) - Chapters 5, 6 and 7• RAPs and Plan of Care section in the RAI-MDS 2.0 Nutrition Care Resource Guide• Facilities DPG. Dietary Documentation Pocket Guide. 2nd ed. Chicago, Ill: American DieteticAssociation; 2004WHAT ARE TRIGGERED RAPS?• Potential or actual clinical problems generated by the computer upon completion of the RAI-MDS2.0 assessment• Help the nutrition care team to identify possible additional nutritional assessment or interventionneedsRAI-MDS 2.0 PROCESSFor Information: 416.327.7625 2ltchrai@ontario.ca2

TRIGGERED RAPS IN THE RAI-MDS 2.0 RAPs cover the majority of areas that are addressed in a typical long-term care home RAPs were created by clinical experts in each of the RAP areas There are 18 RAPsRESIDENT ASSESSMENT PROTOCOLSDeliriumCognitive lossVisual functionCommunicationADL function / rehabilitation potentialUrinary continence / catheterPsycho-social well-beingMood stateBehavioural symptomsActivitiesFallsNutritional statusFeeding tubesDehydration / fluid maintenanceDental carePressure ulcersPsycho-tropic drug usePhysical restraintTRIGGERED RAPS IN THE RAI-MDS 2.0 The most common triggered RAPs that the nutrition care team are responsible for are:- Nutritional status- Feeding tubes- Dehydration / fluid maintenance Other RAPs that the nutrition care team may contribute to are dental care and pressure ulcersBENEFITS OF TRIGGERED RAPS Helps to identify potential nutrition care problems or risks Forms the basis of the nutritional plan of care based on the resident’s needs, strengths andpreferences Enables the nutrition care team to monitor the effectiveness of care plan interventions fromquarter to quarter Promotes interdisciplinary team RAP review and care plan developmentWHAT ARE NON-TRIGGERED CLINICAL PROBLEMS? Potential or actual clinical problems that are NOT triggered upon completion of the RAI-MDS2.0 assessment. Some examples include pain, swallowing problems, constipation and others non-triggered clinical problems are identified by reviewing the completed RAI-MDS 2.0assessmentFor Information: 416.327.7625 3ltchrai@ontario.ca3

Remember:• The nutrition care team is responsible for addressing all nutrition care needs and strengths ofresidents that are not included in RAPs• Depending on individual home’s policy, non-triggered clinical problems can be documented in theprogress notesTRIGGERED RAP AND NON-TRIGGERED CLINICAL PROBLEMS REVIEW PROCESSTRIGGERED RAP REVIEW AN INTERDISCIPLINARY APPROACHTRIGGERED RAP REVIEW PREPARATIONFind out from the RAI Coordinator:1. Who will generate the RAPs and Section V (Resident Assessment Protocol Summary)?2. When will RAPs and Section V be generated?3. What RAPs will the dietary team be responsible for or contribute to?4. When will the care team get together to review the RAPs and develop care plan interventions?TRIGGERED RAP REVIEW PREPARATIONFind out from the RAI Coordinator:1. Who will generate the RAPs and Section V (Resident Assessment Protocol Summary)?2. When will RAPs and Section V be generated?3. What RAPs will the dietary team be responsible for or contribute to?4. When will the care team get together to review the RAPs and develop care plan interventions?TRIGGERED RAP REVIEW PROCESS1. Do you agree with the RAP condition triggered?2. Do you agree with the RAI-MDS 2.0 items associated with the triggered RAP?3. If the RAP is not accurate, notify the RAI Coordinator to correct coding and reprint the RAP.4. If you agree with the RAP and the triggered items, follow the 5-step RAP documentation process.For Information: 416.327.7625 4ltchrai@ontario.ca4

TRIGGERED RAP OR NON-TRIGGERED CLINICAL PROBLEM ASSESSMENT SUMMARY DOCUMENTATIONPROCESSRAP SUMMARY AND SOAP DOCUMENTATIONTFor Information: 416.327.7625 5ltchrai@ontario.ca5

TRIGGERED RAP OR NON-TRIGGERED CLINICAL PROBLEM 5-STEP REVIEW PROCESSPURPOSE Aids critical analysis of RAPs Provides an organized approach to analyzing problems Identifies the need for further assessment Leads to decision making for the plan of care developmentSTEP 1: TYPE OF TRIGGERED RAPIS THIS A NEW, EXISTING OR ADJUSTED RAP?NEW RAPCurrent RAP that has not been previously triggeredEXISTING RAPCurrent RAP previously triggered that has no changes to the RAI-MDS 2.0 trigger itemsADJUSTED RAPCurrent RAP previously triggered that has new RAI-MDS 2.0 trigger items and/or changes to theprevious trigger itemsCLINICAL PROBLEM:New Non-triggered Clinical ProblemCurrent non-triggered clinical problem that has not been previously identifiedExisting Non-triggered Clinical ProblemCurrent non-triggered clinical problem that has been previously identifiedREMEMBER…RAI-MDS 2.0 is not the be-all-and-end-allClinicians are responsible for addressing all needs and strengths of residents regardless of whetherthese areas are included in RAI-MDS 2.0 or RAPs, e.g. quality of life issues, psychosocial needs,behaviours, cultural care, pain and depressionSTEP 2: NATURE OF THE CONDITIONDescribe the resident’s condition/problem in a way that everyone understands. Provide evidence or data tosupport the nature of the problemQuestions to ask: What is the problem? What have you observed to support evidence of this problem? What have you heard to support evidence of this problem? (Interviews with resident, familyand staff)For Information: 416.327.7625 6ltchrai@ontario.ca6

What have you read to support evidence of this problem? (consultations, interdisciplinarynotes, lab reports, vital signs, weights, intake and output records, flow sheets)EXAMPLES:Example 1Nutritional Status RAPTrigger: K4c = leaves 25% or more food uneaten at most mealsResident (Mr.T.) refuses to eat and needs cueing at most meals. He has been leaving 25% ofhis pureed food at lunch and dinner, stating food has no taste.Example 2Dehydration RAPTriggers: J1c = dehydrated; O4e = taking diureticMrs. S. has dry mouth and mucous membrane. She appears lethargic. She consumes lessthan 500cc/day. Staff indicates that Mrs. S. chokes on liquid and coughs more frequently.STEP 3: KEY ISSUES THAT CONTRIBUTE TO THE RAP OR NON-TRIGGERED CLINICAL PROBLEMWhat is the cause of this problem? Are there any complications or changes as a result of thisproblem?How is this RAP or non-triggered clinical problem affecting the day-to-day functioning or wellbeing of the resident?What interventions have you tried?Are they effective?EXAMPLE:The decrease in intake has caused Mr. T. to lose 2.8 kg in the last quarter. The stage onepressure ulcer is now a stage two ulcer and his CHESS score has increased from 1 to 3. He hasnot been taking his evening supplement because he likes to go to bed early. The supplement hasbeen changed to high calorie and recently added to his dinner and he is tolerating well.STEP 4: NEED FOR REFERRALState whether you are making a referral or not.If yes… Which discipline do you need to refer to? Why are you making the referral? For example, a referral will be sent to the speech language pathologist for swallowingassessment.For Information: 416.327.7625 7ltchrai@ontario.ca7

STEP 5: CARE PLANNING DECISIONState whether you will be care planning this problem or not.If yes..• What is the goal of the plan of care?If not to care plan..• State the reason whyRemember…Do not write the plan of care interventions in this step.Save these for the plan of care.EXAMPLES:Current plan of care will be updated with the goal of increasing caloric intake and preventing further skinbreakdown.No plan of care is required because resident has no evidence of dehydration.EXAMPLE OF COMBINED RAPSCombined RAPs: Nutritional Status & Dental CareNutritional Status Triggers:• K5c = Checked (Mechanically altered diet)• K4a = checked (Complains about taste of many foods)• K4c = Checked (Leaves 25% or more food uneaten at most meals)Dehydration Trigger:• J1d = Checked (Insufficient fluid/did not consume all liquids provided)Dental Care Triggers:• K1c = checked (mouth pain)• L1e = checked (oral abscess)COMBINED NEW RAPS: NUTRITIONAL STATUS, DEHYDRATION AND DENTAL CARE1New RAPs. 2Mr. Wiley has a tooth abscess and is experiencing pain when eating or drinking.He has been limiting fluid intake, eating less than 50% of the food at his meals and complainingthat everything tastes bad when eating. 3The mouth pain is impacting his ADL functioning andlimiting his participation in activities. The mechanically altered diet to reduce chewing pain is nolonger effective. 4Referral will be made to MD to discuss antibiotic therapy, and pain medicationand the dentist for possible tooth extraction. 5This RAP will be care planned with the goal ofeliminating the resident’s mouth pain and avoiding dehydration resulting from a reduction in fluidintake.For Information: 416.327.7625 8ltchrai@ontario.ca8

NO EXISTING RAP TRIGGEREDIf existing RAP is not triggered in the next quarter, nutrition care team is responsible for evaluating theeffectiveness of the care plan interventions outlined from the previous quarter.They can then decide whether to maintain, adjust or discontinue the existing RAP problem and the planof care.e.g. Nutritional RAP (triggered by weight loss K3a=1) was triggered in previous quarter, but not in thecurrent quarter due to medication change to improve his behavioral problemThis existing RAP is not triggered in this quarter. Resident gains 1.5 kg this quarter, is able to sitthrough the entire meal and tolerates the high calorie supplements. He is responding well to thebehavioral medication change - less agitation, more cooperative and alert. Care plan will be maintainedfor monitoring no further weight loss fluctuation.PLAN OF CAREWHAT IS A RESIDENT PLAN OF CARE?A communication tool for care team members in all shifts on how to care for the resident.CHARACTERISTICS OF A GOOD CARE PLAN• Current• Accurate• Clear• Useful/practical• Individualized - meets the needs and wishes of the resident• Interdisciplinary - reflects team contributions• Comprehensive - addresses physical, psychosocial, spiritual and medical• Accessible by all staffPLAN OF CARE: PROCESS AND COMPONENTSFor Information: 416.327.7625 9ltchrai@ontario.ca9

PLAN OF CARE DEVELOPMENT1. Problem Statement:State problem, etiology/cause, signs and symptoms (PESS)State the problem clearly using data or RAP triggers to support your problem statemente.g. Gradual weight loss related to swallowing difficulty and recent pneumonia as evidenced by:leaving 25% or more food uneaten at most meals and complains about the taste of foods2. Goal:• Include improvement goals, prevention goals, palliative goals or maintenance goals• Should be Specific, Measurable, Acceptable, Realistic and Time limited (SMART)• State in terms of resident achievemente.g.5. Resident will return to her usual goal weight by next quarter6. Resident will eat more than 75-100% of food at most meals by Aug 123. Interventions:• The steps that staff takes to assist the resident to achieve the identified goal(s)• Must have short, concise, realistic, measurable and achievable instructions, which can beunderstood by all staff• Should be documented in the health record according to home’s policye.g.• Offer resident her special supplements in between meals• Monitor and document food intake for one week and then re-evaluate4. Responsible Person/Discipline:• Identify care team member(s) who is responsible for the implementation and/or monitoring ofthe outcome5. Review Date:• Set target date to review the goals and document on quarterly basis whether those goals havebeen metHELPFUL TIPS ON MAKING THE PLAN OF CARE REALISTIC AND USEFUL7. Have a plan of care that is clear, current, accurate, useful and accessible by all care teammembers. Focus on the quality of content in the plan of care rather than quantity of words.(quantity does not mean quality!)8. Include the inputs of the resident, significant others and the front line staff in the care plandevelopment9. Do not address every RAP on the plan of care, address only those RAPs and non-triggered clinicalproblems that need preventative measures or need to be closely monitored. The plan of care mayreflect:- Rehabilitation- Prevention of complications- Prevention of current problems from worsening- Palliative careFor Information: 416.327.7625 10ltchrai@ontario.ca10

RAP IMPLEMENTATION STRATEGIES Complete the “Preparing for RAPs and Care Planning Checklist” in the Nutrition Care Resource Guide Participate in the RAPs and care planning interdisciplinary team review, according to home’s policy andpractice Conduct self audit using the RAPs auditing tool or have another team member such as the RAI Coordinatoraudit your RAP documentation and provide feedback Develop policy to support RAP implementationFor Information: 416.327.7625 11ltchrai@ontario.ca11

Overview of RAPs and Care Planning TimelinesOVERVIEW• RAPs and Care Plan Completion Timelines- Admission- Quarterly- Annual- Significant Change in Health Status• RAPs and Care Plan Timelines ResponsibilityADMISSION RAP TIMELINEThe Minimum Data Set (MDS) and Resident Assessment Protocols (RAPs) cannot be completed prior to theAssessment Reference Date (ARD).The ARD is the last day of the observation period.RAI-MDS 2.0 assessment and RAPs Assessment Summaries must be completed by day 14 for newadmissions.Project Recommendation:Complete RAPs documentation between day 11 to 14.ADMISSION CARE PLAN TIMELINEThe resident’s plan of care must be completed by the interdisciplinary team within 21 days of admission orwithin 7 days of completion of the RAI-MDS 2.0 and RAPs.The plan of care should be initiated within 24 hours of admission and be finalized within 21 days ofadmission or within 7 days after RAP Assessment Summaries are completed.For Information: 416.327.7625 12ltchrai@ontario.ca12

NEW ADMISSION RAP AND CARE PLAN TIMELINESMaximum 7 days Maximum 7 days Maximum 7 daysAdmissionDAY 0 DAY 7 DAY 14DAY 2124-Hour7-day1. Complete MDSCare Plan Observation PeriodAssessmentComplete Care Plan2. Generate RAPs3. Complete RAPAssessmentSummariesARDR2bARD must be within 14 daysof admission. The Projectrecommends ARD on MDS day 7.Vb1 + Vb2Vb3 + Vb4QUARTERLY RAP AND CARE PLAN TIMELINES The resident’s RAPs and plan of care must be reviewed and where necessary revised, within 92 days of theprevious assessment, by the physician, nursing staff, the dietitian or nutrition manager, and other care teammembers as appropriate. Quarterly RAP Assessment Summaries can be completed earlier than 92 days (every 3 months) but notlater. Quarterly plan of care must be completed within 7 days after completion of RAI-MDS 2.0 assessment andRAP Assessment Summaries.QUARTERLY RAP AND CARE PLAN TIMELINESM axim um 7 days M aximum 7 days Maxim um 7 daysDAY 0 DAY 7 DAY 14DAY 217-dayObservation Period1. Comp lete M DSAssessmentComplete Care Plan2. Generate RAPs3. Comp lete R APAssessmentSum mariesARDR2bWithin 92 days of ARD of last Fullor Quarterly AssessmentVb1 + Vb2Vb3 + Vb4For Information: 416.327.7625 13ltchrai@ontario.ca13

ANNUAL RAP AND CARE PLAN TIMELINES The resident is assessed annually by the interdisciplinary care team using the RAI-MDS 2.0 FullAssessment within 366 days of the previous Full Assessment, along with RAPs and care plans review andupdates. Annual RAI-MDS 2.0 Assessment and RAP Assessment Summaries can be completed earlier than 366days but not later. The plan of care must be completed within 7 days after completion of RAI-MDS 2.0 assessment and RAPAssessment Summaries.ANNUAL RAP AND CARE PLAN TIMELINESM axim um 7 days M aximum 7 days Maxim um 7 daysDAY 0 DAY 7 DAY 14DAY 217-dayObservation P eriod1 . C om p lete M D SAs se ss m e ntComplete Care Plan2 . G ene rate R APs3 . C om p lete R APAs se ss m e ntSum m a riesARDR2bWithin 366 days of ARD of last FullAssessm entVb1 + Vb2Vb3 + Vb4SIGNIFICANT CHANGE IN STATUS RAP & CARE PLAN TIMELINES Any significant change in resident’s condition, either decline or improvement, must be reassessed alongwith RAPs by the interdisciplinary care team using the RAI-MDS 2.0 Full Assessment within 14 days of thedetermination in the change in status. Where a significant change in the resident’s health status has resulted in the completion of aninterdisciplinary assessment, then the interdisciplinary assessment may replace the quarterly assessmentfor that quarter. The plan of care must be completed within 7 days after completion of RAI-MDS 2.0 assessment and RAPAssessment Summaries.For Information: 416.327.7625 14ltchrai@ontario.ca14

M axim um 7 days M aximum 7 days Maxim um 7 daysDAY 0 DAY 7 DAY 14DAY 217-dayObservation Period1 . C om p lete M D SAs se ss m e ntComplete Care Plan2. Generate RAPs3 . C om p lete R APAs se ss m e ntSum m a riesARDR2bARD must be within 14 days ofdetermining that a significantchange has occurredVb1 + Vb2Vb3 + Vb4RAP & CARE PLAN TIMELINE RESPONSIBILITY Review the RAI-MDS 2.0 scheduler weekly - know which residents are due for completion of RAPAssessment Summaries and care plan reviews’ Attend the RAPs care team review and obtain input from team members for nutrition care plan development. Communicate to back-up assessor and RAI Coordinator immediately if unable to complete assessmentwithin required timelines. Complete all RAP Assessment Summaries and plan of care according to timelines.For Information: 416.327.7625 15ltchrai@ontario.ca15

Preparing for RAPs and Care PlanningChecklistThe following checklist summarizes the important tasks for the nutrition care team to review or implement for RAPs andCare PlanningCompletionAction ItemDate1. Meet with the RAI Coordinator to discuss the following:- determine nursing back-up for a dietitian and nutrition manager, for completion of RAPs assessmentsummary documentation and care planning- method of communicating RAPs, including resident with significant change in health status- the RAP review model in the home, e.g. weekly team meeting to review RAPs- printing and method of communication of Section V RAP summary and its triggers- RAPs and Care Planning completion timelines- correcting inaccurate coding – who will be responsible- set up monthly update meetings where you will share feedback, implementation challenges andstrategies2. With the nutrition care team members:- Establish the roles and responsibilities of dietitian and nutrition manager related to RAPs and careplanning- Establish workload distribution and coordination of RAPs and care planning within the department3. Set up the training date and time with the RAI Coordinator for:- RAPs and care planning- RAPs and care planning software4. Determine who, from the food service department, will attend the training.5. Access and print the RAPs and care planning chapter of the Nutrition Care Resource Guide6. Contact home’s RAI – C for training in:- RAPs and care planning- RAPs and care planning software (don’t forget to take the RAPs and Care Planning SoftwareOrientation Checklist to training)7. Ensure that nutrition care team members review the RAPs and care planning chapter from the RAI-MDS2.0 Nutrition Care Resource Guide.8. During the early period of RAPs and care planning practice, find a RAPs and care planning buddytogether with the RAI Coordinator. The buddy can be the RN or RPN.9. Arrange the time for RAI Coordinator to audit the RAPs and care planning for accuracy andcomprehensiveness.10. In the CIHI User’s Manual, read chapters related to RAPs, nutritional care RAP and other RAPs asrelevant to home policy and RAI-MDS 2.0 practice.11. If unable to meet a timeline, speak with the RAI Coordinator immediately to identify new target timeline.For Information: 416.327.7625 16ltchrai@ontario.ca16

RAPS and Care Planning Software OrientationChecklistThis checklist will serve as a guide for dietitians and nutrition managers during their RAPs and care planning softwareorientation. Please feel free to add other checklist items that are specific to your software. At the end of yoursoftware orientation, you should be competent in performing the following computer skills.1.2.3.4.5.6.7.8.9.Skills Checklist Notes/Comments CheckRAPs and Care PlanningLog in and open the RAP software folderFind resident(s) for RAP reviewLocate Section V: RAP SummaryDocument on Section V: column “b”Access RAP triggers for each RAPLocate the 5-steps RAP documentation sectionOpen “drop down” boxes and click, if applicableView previous RAP assessment summariesLocate the ‘Standard Statement’, if available in the software10. Document combined RAPs within the software if capability exists11.Identify where to document or review non-triggered RAPs12.13.14.Access spell check if available in the softwareSign off and date RAPs documentationOpen and navigate through the Care Planning folder: problem, goal,intervention etc.15.16.17.18.Create a new care plan and edit existing care planOpen care plan library and create individualized care planinterventionsAccess other supporting documents within the software to completethe care plan, for example flow sheet and KardexPrint Care PlanFor Information: 416.327.7625 17ltchrai@ontario.ca17

The College of Dietitians of OntarioDocumentation Requirements adapted forLong-Term CareThe College of Dietitians of Ontario developed a “Record Keeping Guidelines for Registered Dietitians 2004”. Theguidelines are available to Dietitians to interpret and accompany the record keeping regulations.This document provides practical information on record keeping and documentation standards for RegisteredDietitians (RDs) to meet their professional, legal and ethical obligations. These guidelines apply to all practice settingsregardless of the type of system or method used.Dietitians can play an important role in ensuring that workplace systems, processes, policies and procedures facilitatethe implementation of record keeping and documentation guidelines. Within each home, the dietitian is required tofollow home specific policies around record keeping as well as any regulations or legislation, which exists fordocumentation.For Information: 416.327.7625 18ltchrai@ontario.ca18

The College of Dietitians of OntarioDocumentation Requirements adapted for Long-Term CareItemDocumentation Requirements Adapted forLTCBased on the College’s Proposed RecordsRegulation1 The client health record includes the date ofeach of the client's visits to the dietitian or by thedietitianSection (7)(b) of the College’s ProposedRecords Regulation2 The client health record includes the reason forthe referral. Section (7)(d) of the College’sProposed Records Regulation3 The client health record includes the client’srelevant medical history including medical andsocial data related to nutritional intervention.When background health information has beenprovided by another practitioner, it need not beduplicated; however, a reference to theappropriate section must be included. Section(7)(e) of the College’s Proposed RecordsRegulationRecommended Application to RAI-MDS 2.0There is no designated location in the RAI-MDS 2.0 to capture residents’ visitsby the dietitian. Dietitian can document his/her visits under the RAP or nontriggeredclinical problems assessment summary or in progress notes.Reason for referral can be documented under Step 4 of the RAP assessmentsummary or in the progress note. A RAP assessment summary has 5components or steps that the help guide the professional through theassessment process.1. Type of RAP2. Nature of the problem3. Key issues that contribute to the RAP4. Need for referral and reason for the referral5. Care planning decisionIn the Appendix, a sample Dietitian Referral Form contains examples ofreason for the dietitian referral.The RAI-MDS 2.0 is an interdisciplinary tool. In documenting the client care, itis important to clearly indicate what information was used to form yourassessment and care plan. Where information has been gathered andrecorded elsewhere in the client record, there is no need to repeat thatinformation, as long as it is referenced in the nutrition assessment. Forexample, if information contained elsewhere in RAI-MDS 2.0 (e.g. section H) isrelevant or has the potential to be relevant to the nutrition assessment andcare plan, it would be appropriate to simply state “see RAI-MDS 2.0 section H2regarding bowel elimination pattern.”. Other examples would include “see SPL swallowing assessment note of May 13th, 2008” “see Nursing notes of June 2 nd , 2008” “see Food and Fluid intake records of May 5-10, 2008To avoid the perception that problems have been overlooked in theassessment process, all relevant, or potential to be relevant clinical concerns,should be documented in the progress notes or in the RAP/non triggered RAPassessment summary.Dietitians can trust the assessment entries/coding made by theirinterdisciplinary team members; however, there may be circumstances wherethe information recorded in the chart should cause the dietitian to questionsomeone else’s entries. Validation of the assessment by the other members3-37 of the team is a natural part of the process.Decisions to care plan or not to care plan some of the RAPs or non-triggeredclinical problems can be documented under Step 5 of the RAP Care PlanningDecision or in the progress notes depending on the individual home’s policy.For Information: 416.327.7625 19ltchrai@ontario.ca19

4 The client health record includes the assessmentconducted, the findings obtained, the problemsidentified, the goals for nutrition intervention andthe nutrition care plan. Section (7)(f) of theCollege’s Proposed Records RegulationThe RAI-MDS 2.0 assessment instrument is a primary source document. Ittriggers 18 RAPs (clinical conditions) that are commonly found in a typicallong-term care home.On admission, the dietitian is required, as appropriate, to gather furtherrelevant nutrition information or assessment that is not identified by the RAI-MDS 2.0 instrument or triggered by RAPs. Part A of this resource guideidentifies nutrition care areas with recommended sample questions that arenot covered by RAI-MDS 2.0. This process enables the dietitian to identify thenon-triggered nutrition care RAPs for care planning.3-38At a minimum, the dietitian and/or nutrition manager will review and update thenon-triggered clinical problems quarterly or when there is a significant changein resident’s health status or a dietitian referral. Depending on home’s policy,both dietitians and nutrition manager can conduct the analysis of the RAPsand the clinical information can be documented in the progress notes or inRAPs assessment summary documentation.The analysis of the RAP or non-triggered RAP problems based on the problemidentification items (triggered conditions) can be documented using thefollowing 5-step critical analysis:1. Type of RAP or Non-Triggered RAP:- New RAP (Current RAP that has not been previously triggered)- Existing RAP (Current RAP previously triggered that has no changes tothe RAI-MDS 2.0 trigger items )- Adjusted RAP (Current RAP previously triggered that has new RAI-MDS2.0 trigger items and/or changes to the previous trigger items)2. Nature of the resident’s condition: this includes identifying data that supportor contributes to the assessment and interpretation of the findings. 17.9Essential Competencies for Dietetic Practice 20043. Key issues that contribute to the RAP: this includes the analysis of keyissues and your conclusions 17.10 Essential Competencies for DieteticPractice 20044. Need for referral and reason for referral5. Care planning decision5 The client health record includesrecommendations made by the dietitian for dietorders, nutrition supplements, test and /orconsultations to be preformed by any otherperson. Section (7)(g) of the College’s ProposedRecords Regulation.6 The client health record includes particulars ofnutrition care that was commenced but notcompleted, including reasons for noncompletion.Section (7)(l) of the College’sProposed Records Regulation7 Every entry must be dated and the identity of theperson who made the entry must be identifiable.Section 8 of the College’s Proposed RecordsRegulationRecommendations made by dietitian for diet orders, nutrition supplements;tests and/or consultations will be documented in the plan of care and/orprogress notes electronically or in hard copy, depending on home policy.The specific location of where to document the particulars of nutrition care thatwas commenced but not completed will depend on the home’s policy. Suchinformation can be documented in the progress note or in Step 2 of the RAPassessment summary documentation.Documentation entries in the resident’s health record (e.g. consultations,assessment, care plan, etc.) must be dated and signed off by the person whohas made the entry. Check with the RAI Coordinator, to see if the software has‘built-in’ capacity for electronic signature and date.For Information: 416.327.7625 20ltchrai@ontario.ca20

8 Documentation by the dietitian in the clienthealth record should be permanent and cannotbe altered - in ink or electronic medium that ispermanent, no blank lines between writtenentries or using electronic medium that does notallow altering. Section E (11)Record KeepingGuidelines, 20049 The client health record should be residentfocusedincorporating resident and/or familygoals. Section E (7) Record Keeping Guidelines,2004Home develops policy to determine who has access to make changes withinthe RAI-MDS 2.0 coding, RAPs documentation and care plan. Softwarevendor may have built-in lock or read only features in the software.The dietitian should discuss with the home the need to confirm with softwarevendor an audit feature to enable auditing of information for example: whatinformation was entered or changed, when and by whom.The process for accurately assessing each resident includes the gathering ofinformation from multiples sources, in particular from the resident and his/herfamily. RAI-MDS 2.0 is a comprehensive, multi-domain assessment of eachresident’s functional status. When completed, the triggered RAPs andoutcome measures that identify each resident’s needs and or/strengthsfacilitate the development of a resident-focused plan of care. It is important tocontinue to include the resident and his/her family in decision-making for goalsof care and the development of the care plan interventions.Evidence of resident/representative input and source of diet history informationcan be documented in the RAP/non-triggered RAP assessment summary orthe interdisciplinary progress note.Note: a record of consent should be obtained from clients or substitutedecision makers whenever dietitians are recommending a nutritional therapy(therapeutic diet, tube feeding or TPN). While a signed consent form from aclient may be desirable, it is not necessary. Section C Record Keepingguidelines 2004.10 The client record includes Progress notescontaining a record of services rendered,subjective and objective re-evaluation andchanges in the client's nutritional status. Section(7)(h) of the College’s Proposed RecordsRegulation11 The dietitian uses a structured system to identifyclients at nutrition risk. Section 17.1 EssentialCompetencies for Dietetic Practice 200612 Documentation by the dietitian in the clienthealth record should be signed (name andcredential-RD) by the individual who saw theclient. Never chart or sign an entry on behalf ofanother dietitian. Section E (14)Record KeepingGuidelines, 2004The specific location of where to document or demonstrate ongoing monitoringand evaluation of resident’s nutritional status will depend on the home’s policy.This may include incidental charting in the progress notes, or in the RAP/nontriggered RAP Summaries Step #2The RAI-MDS 2.0 offers standardized baseline information for initiating acomprehensive nutritional assessment. It identifies some key measurableindicators of nutritional risk. The dietitian/nutrition manager is required toaddress all pertinent diagnoses, health status, individual’s eating habits,religious and cultural preferences and any nutrition care needs that have orhave not been identified in RAI-MDS 2.0 and/or triggered by RAPs (taken fromthe Resource Guide for Nutrition care - Part A).Following the RAI-MDS 2.0 assessment and RAPs analysis, the dietitian will: Use his/her clinical judgment to make a decision to conduct furtherassessment if appropriate; andDetermine if the resident is at nutritional risk; assigning nutritional risk level toresident (for example: high, moderate or low) is not a requirement, dependingon home policyConsult the RAI Coordinator to see if the software includes areas for the nameand credential of the individual who saw the resident.For Information: 416.327.7625 21ltchrai@ontario.ca21

Nutrition Assessment and Care Planning Guidelines forRegistered DietitianThe College of Dietitians of Ontario has a reference document entitled “Essential competencies for Dietetic Practice 2006”.Sections 17 and 18 are some of the competency statements and performance indicators for client care. These statements apply to all dietitians practicing inthe area of client care and are to be used as guidelines for nutritional assessment and care planningNutrition Care Documentation ChecklistSec (7) (e)The client’s health record must include the client’s relevant medical history including social data related to nutritionalintervention. * *17.1 Uses a structured system to identify clients at nutrition risk. *17.2 Determines psychosocial factors that may influence nutrition intake / status.*17.0 Conductscomprehensivenutritionassessments17.3 Conducts and analyzes client diet history.*17.4 Completes accurate analysis of food records. *17.5 Analyzes and compares food intake with nutrition requirements. *17.6 Assesses client nutrition status through physical observation and anthropometric measures.*17.7 Reviews and assesses relevant laboratory data. *17.8 Determines potential nutrient drug interactions. *17.9 Interprets findings of comprehensive nutrition assessment to identify normal, abnormal and deviant states of health. *For Information: 416.327.7625 22ltchrai@ontario.ca

17.10 Draws relevant conclusions from nutrition assessment data. *17.11 Prioritizes identified health needs in consultation with clients / care givers and interprofessional team*18.1 Integrates assessment data in development of the nutrition care plan.18.2 Considers comorbidities in development of the nutrition care plan.*18.3 Consults with the interprofessional team in development of the nutrition care plan.*18.4 Identifies nutrition goals and develops nutrition care plan to achieve planned outcomes incollaboration with clients.*18.0 Develops,implementsand evaluatesnutrition18.5 Formulates meal plans to achieve planned outcomes.*18.6 Determines appropriate formula and feeding route for clients.* May include: oral, enteral, parenteral18.7 Provides nutrition education to clients / caregivers. *18.8 Coordinates implementation of nutrition care plan. *18.9 Implements strategies and supports for those unable to manage their own care. *18.10 Assesses client progress in achieving planned outcomes. *18.11 Evaluates effectiveness of nutrition care plan in achieving planned outcomes ** “Essential competencies for Dietetic Practice 2006” , The College of Dietitians of Ontario** “”Record keeping guidelines for Registered Dietitians 2004”For Information: 416.327.7625 23ltchrai@ontario.ca2323

Sample RAPs Documentation - Essential Competencies forDietetic PracticeTriggered RAPs are generated by computer software and summarized in Section V. A summary of RAI-MDS 2.0 items (triggers) for each triggered RAP isalso available for the nutrition care team’s review to ensure coding accuracy (see reference in RAI-MDS 2.0 User’s Manual).'Non-triggered clinical problems' are identified by reviewing the completed RAI-MDS 2.0 assessment. Some examples of non-triggered clinical problems are:- intake from one of the food groups restricted - BMI over 29 or less than 19 - swallowing problem- food related allergies or intolerances - abnormal lab values - drug nutrient interactions affecting intake- physical signs of malnutrition - low body weight - unstable dysphagiaOther examples of non-triggered clinical problems related to dining are: the ability to make choices in the dining room, suitability of tablemates, diningbehaviours and positioningRAP Process Step 1Type of RAPReference to EssentialCompetencies for DieteticPracticeStep 2Nature of theproblemAdmission:17.2, 17.3, 17.4, 17.5, 17.7, 17.8Quarterly adjusted or combined:17.2, 17.5, 17.7, 17.8Step 3Key issuesandanalysisStep 4NeedforreferralStep 5Rational forcareplanningAdmission: 17.1, 17.3, 17.4, 17.5,17.6, 17.7, 17.9, 17.10, 17.11Quarterly (adjusted or combined):17.1, 17.4, 17.5, 17.6, 17.7, 17.8,17.9, 17.10, 17.11Quarterly (existing): 17.1, 17.6, 17.7,17.8, 18.11Care PlanInterventions18.1Newinterventionsare updatedin the plan ofcare asrequiredProgress Note ChartingIncidental charting of residentprogress and evaluation ofintervention effectivenessQuarterly: Evaluation of care planinterventions effectiveness inprogress noteApplication of the RAP process including RAP assessment summary documentation and the plan of care is illustrated in the following example ofMrs. K.For Information: 416.327.7625 24ltchrai@ontario.ca2424

RAPProcessLeaves25% ormore fooduneaten atmost mealsApril 30/08Step 1Type ofRAPStep 2Nature of the problemNew admission RAP. Mrs. K is alert,cooperative and friendly. She seemsto understand English, followsinstructions well, but speaks onlybroken or one word English. The nextof kin, Mrs. K’s son was contacted byphone on April 30. He visits themother most evenings after work. Heinformed writer that his motherunderstands English, but does notspeak it very well.During meal observation, it was notedthat she chews very slowly, picks ather food and has been consistentlyleaving 25% or more food uneaten ateach meal (see Food and Fluid intakerecords May 1-5th). Her denturesappear to be loose and making noisewhen she chews. Most meals, sheadds both salt and pepper to her foodand does not seem to be interested inher food. It was reported by nursingstaff that during family and friends’visits, Mrs. K ate homemade Koreanfood. She ate all of it and enjoyed herown cultural food.Weight is 49.9kg and no recent weightlosses noted by son.Step 3Key issues andanalysisStep 4Need forreferralStep 5Rational forcare planningMrs. K told her son that she does not like thefood in the home. It is too plain; she is used tospicy food with more varieties. The son issuggesting bringing in some Korean condimentsfor his mother to add to her food.The son also notices his mother’s loose dentureand is trying to set up an appointment for her tovisit the dentist. Mrs. K prefers smaller portionsize. She also likes green tea with all meals andsnacks. This is not presently available on menu.Referral to dentist will be made by son related toMrs. K’s loose denture.Care plan will be developed to improvenutritional intake.Care Plan Interventions• Label Mrs. K’scondiments and havethem available for her touse during all meals.• Monitor Mrs. K’s foodintake and record herintake for the next 7days; if improved, noaccurate intake required• Follow up with the sonregarding the dentistappointment• Have the menu availablefor the son to select withhis mother during visitand forward to nutritionmanager.• Instruct the son to recordthe homemade foodintake that the motherconsumes for the next 7days• Source appropriate greentea for meals and snacks• Instruct front line servingstaff to refer to selectedmenuProgress Note ChartingMay 12, 2008Mrs. K’s appetite seems toimprove with the newcondiments. For the past 7days, she ate most of herfood during all meals. Herson brought additionalpreserved vegetables thatare kept on the unit fridgefor Mrs. K. to use. Shegoes to the fridgeindependently and obtainsher condiments duringmealtime. She is still eatingvery slowly contributed bythe loose dentures. Theappointment is set for May31.For Information: 416.327.7625 25ltchrai@ontario.ca2525

RAP Process Step 1Type ofRAPLeaves 25% ormore fooduneaten at mostmealsChewingproblemsMouth PainJuly 26/08Step 2Nature of theproblemAdjusted and combined RAP(nutritional status and dental careRAPs).Dentures were not used duringmeals until they are properlyfitted. Her next denture fittingappointment is Aug. 25. Residenthas chewing difficulties. She isleaving 25% or more fooduneaten at each meal. Son isvery worried.Weight has declined this quarterfrom 49.8kg to 47 kg because ofinsufficient caloric intake.Step 3Key issues andanalysisStep 4Need forreferralStep 5Rational forcare planningNursing note stated that analgesic was orderedon June 30 to help with Mrs. K’s mouth pain withsome relief.Resident is chewing very slowly, recent mincedtexture was ordered with improvement in herchewing ability.High calorie supplement will be added to hermeals. Son continues to do menu selections butthe resident is still not eating well. Son wouldlike staff to order take out from local Koreanrestaurant. Listing of favourite orders left inresident's top drawer.Referral for denture fitting appointment on Aug25.Care plan will be modified to improve nutritionalintake and monitor mouth pain.Care Plan Interventions• Continue to monitor Mrs.K food intake for the next2 weeks and thenreassess• Have menu available forson to select on his visits• Instruct son to recordintake of homemadefoods• Remind cooking staff tomince take out food• Offer analgesic if residentappears to beuncomfortable chewingProgress Note ChartingAug 31, 2008Mrs. K likes her take outfood. She is morecomfortable chewing duringmealtime when givenanalgesic prior to hermealtime as stated innursing note (Aug 2).With the new denture, Mrs.K is eating slowly, adjustingto the new denture - is stillleaving 25% or more foodat most meals and takinganalgesic for her mouthpain with moderate effect.Son continues tosupplement Mrs. K’s dietwith homemade food.For Information: 416.327.7625 26ltchrai@ontario.ca2626

RAP Process Step 1Type of RAPLeaves 25%or more foodChewingproblemsMouth PainSept 28/08Existing andcombined RAP. Mrs.K’s clinicalassessment has notchanged from lastassessment. She isstill leaving 25% ormore food uneatenat most meals.Weight has notchanged at 47kg -continues to tolerateher high caloricintake. She is stillbelow her IBW (95%of IBW) range but ismore stable withcurrent interventions.DRS and CHESSscores haveimproved sinceadmission.According to thedental consultation, itwill take severalweeks for Mrs. K toadjust to her newdenture.Step 2Nature of theproblemStep 3KeyissuesandanalysisStep 4Need for referralStep 5Rational forcare planningMouth pain related to the denture is still managed by analgesicwith good effect (Nursing note, Sept 2). Dietary staff is servingMrs. K first since she is taking longer time to eat. This way, shewill not be eating alone after all other residents finished. Soncontinues to do menu selections and resident is gradually eatingmore facility foods. Take out food was given approx once perweek. Next dentist appointment is scheduled for Oct 3rd.No referral is requiredCare plan goals and interventions have been reviewed by thecare team and continue to be effective in maintaining the RAPproblem.Care Plan Interventions• Continue to monitorintake for the next 2weeks and thenreassess• No changes with theother interventionsProgress Note ChartingOct 11, 2008Mrs. K’s appetite seemsto have improved. Sheis eating better withminced texture slowly(nursing note, Oct 4).Mouth pain is relievedwith analgesic. Residentis still not used to thedenture; she oftenremoves it and places itin the teacup. Willcontinue to monitornutritional intake, mouthpain and chewingproblem.For Information: 416.327.7625 27ltchrai@ontario.ca2727

RAPProcessNontriggeredClinicalProblem:ConstipationOct 30/08Step 1Type ofRAPStep 2Nature of the problemNew non-triggered clinicalproblem: ConstipationResident clinical assessment hasnot changed significantly fromlast review with the exception ofbowel regularity.She is constipated; flow sheetindicated Mrs. K’s bowel patternhas changed from 2-3 times aweek to once a week with greatdeal of effort (use of enema andlaxative) (see nursing note, Oct27). She is not meeting her1800cc fluid requirement.Analgesic for her arthritic painhas been increased, noted innursing note (Oct 10).Step 3KeyissuesandanalysisStep 4Need forreferralStep 5Rational for careplanningRecent pain medication change alteredMrs. K’s bowel pattern. Home bowelprotocol was implemented. Fibrerequirement is 30g per day. Currentmenu provides 25g of fibre. Additionalsoluble and insoluble fibre will be addedto meet minimum of 30g requirement.Nutrition risk level has changed from lowto moderate due to modified diet textureand constipation.No referral is required.Care plan will be developed to improvebowel regularity.Care Plan Interventions• Add prune juice on Mon, Wed,and Fri. at breakfast. Stewedprunes to be provided Tues,Thurs, and Sat. at breakfast.• Add 2 Tbsp of ground flax to begiven in cereal choice. Fresh fruitchoice to be given at pm snack.• Offer fluid to resident andencourage her to consume• Record and document fluid intakefor 2 weeks and re-assess.• Report to RD immediately if fibreis not tolerated well or not able tomeet fluid requirementProgress Note ChartingNov 18, 2008Resident has tolerated thehigh fibre and with muchencouragement, she is ableto achieve the 1800cc/dayrequirement (Nursing note,Nov 8). No enema wasgiven in the past week andthe resident has normalbowel movement twice aweek. Will discontinue fluidmonitoring if conditionmaintains next week.Note: The above example did not include identification of risk level. Home policy will establish the method to determine nutrition risklevel.For Information: 416.327.7625 28ltchrai@ontario.ca2828

Dietitian ReferralDietitian Referral OrientationOVERVIEW• Nutrition Care and Its Importance• Goal of Nutrition Care• Purpose of a Dietitian Referral• To Whom Do You Make a Dietitian Referral?• How to Make a Dietitian Referral?• When to Initiate a Dietitian Referral?WHAT IS NUTRITION CARE?Nutrition care within a Long-term Care setting includes:• Provision of a socially stimulating and pleasant dining environment• Enjoyable meals• Adequate and nourishing food• Assistance with eating including modified diets, textures, supplements and/or tube feeding• Supporting of resident choiceWHY IS NUTRITION CARE IMPORTANT?• Good nutrition is part of dignity in care and quality of life• An absence of good quality, attractive and nutritious food for older people and a failure to provide support at mealtimesfor those who need it constitutes a lack of respect for people’s dignity• Good nutrition care is central to older people's good health. It increases their resistance to disease and ability to recoverfrom illness, trauma or surgery.• Good nutrition and hydration and enjoyable mealtimes can improve the health and well-being of older peopleGOAL OF NUTRITION CARETo ensure residents have good nutrition care, adequate hydration and enjoyable mealtimesPURPOSE OF A DIETITIAN REFERRALTo provide guidelines for the interdisciplinary team members to: Identify residents at nutrition risk, and Make timely dietitian referral to meet the needs of residentsTO WHOM DO YOU MAKE A DIETITIAN REFERRAL?Depending on home’s policy, you communicate your resident’s dietary concerns or needs to the dietitian or the nutrition manager.HOW TO MAKE A DIETITIAN REFERRAL?Depending on home’s policy, you may have to fill out a dietitian referral form or document in a communication book or e-mail yourrequest to the clinician dietitian or nutrition manager.WHEN TO INITIATE A DIETITIAN REFERRAL?Depending on home policy and practice, make a dietitianreferral when:• There is a new admission or• The resident returns from hospital with nutrition implications or significant changes in health status• The resident is identified as being at risk for nutritionFor Information: 416.327.7625 29ltchrai@ontario.ca

Make a dietitian referral when your residents have an INTAKE PROBLEM such as:• Significant change from usual pattern in food/fluid for two of the three meals over a period of seven days• Refusal to eat (> 3 consecutive meals)• Leaves 25% or more of food for two of the three meals over a period of seven days• Leaves 25% or more of fluid for two of the three meals over a period of seven daysMake a dietitian referral when there is a TEMPORARY OR PERMANENT DIET CHANGE for:• Fluid consistency• Therapeutic diet• Texture• Enteral feeding• SupplementMake a dietitian referral when there is a CHANGE IN RESIDENT’S MEDICAL CONDITION such as:• Aspiration pneumonia (diagnosed by the Physician)• Change in health status with nutrition implications (e.g. CVA, anemia, depression, colostomy, Crohn’s disease, gastricreflux etc.)• Chronic urinary tract infections• Frequent episodes of hyperglycemia/hypoglycemiaMake a dietitian referral when there is a CHANGE IN RESIDENT’S MEDICAL CONDITION such as:• Abnormal laboratory values• A new diagnosis of diabetes or the introduction of insulin to a diabetic plan of care• A new diagnosis of a metabolic condition (e.g. kidney disease, COPD, liver failure, CHF) that affect nutrition or hydration• Palliative care with nutrition implicationsMake a dietitian referral when resident shows the following SIGNS AND SYMPTOMS:• Altered skin integrity (not rashes or bruises)• Constipation with nutrition implications• Difficulty chewing or swallowing (e.g. coughing, choking, pocketing etc.)• Food related allergies or intolerances• Physical signs of malnutrition or low body weightMake a dietitian referral when resident shows the following SIGNS AND SYMPTOMS:• Unplanned gradual weight loss below goal weight• Undesirable, unplanned, progressive weight change (>5% in one month, >7.5% in 3 months and >10% in 6 months toone year)• Signs and symptoms of dehydration• Vomiting and/or diarrhea lasting more than 72 hours• Dental issues affecting nutrition intake e.g. mouth pain, broken or loose teethNutrition manager or nursing make a dietitian referral when resident shows the following RISKS:• Intake from one of the four food groups restricted (vegetables and fruits, grain products, meat and alternatives, milk andalternatives)• Change in self feeding ability• Moderate to high nutrition risk findingsDepending on home policy and practice, make a dietitian referral when the following RAI-MDS 2.0 RAPS are triggered:10. Nutritional Status11. Feeding Tubes12. Dehydration/Fluid Maintenance StatusFor Information: 416.327.7625 30ltchrai@ontario.ca30

13. Dental Care14. Pressure UlcersDepending on home policy and practice, make a dietitian referral when the following RAI-MDS 2.0 OUTPUTS have occurred:15. ADL Scale Scores affect eating (G1ha),16. Depression Rating Scale (DRS) Scores affect eating17. Cognitive Performance Scale (CPS) Scores affect eating18. Changes in Health End Stage Disease and Signs and Symptoms (CHESS) with changes in:- Vomiting - (J1o)- Dehydration - (J1c)- Leaving food uneaten - (K4c)- Weight loss - (K3a)Depending on home policy and practice, a dietitian referral is made when the following RAI-MDS 2.0 QUALITY INDICATORS aretriggered:• Percent of residents who decline in mood from symptoms of depression• Percent of residents whose cognitive function has worsened• Percent of residents with worsening bowel incontinence• Percent of residents who have unexplained weight loss• Percent of residents with a feeding tube• Percent of residents who have a pressure ulcer stage 2 – 4• Percent of residents with worsening pressure ulcers stage 2 – 4• Percent of a resident with newly occurring pressure ulcer stage 2 - 4For Information: 416.327.7625 31ltchrai@ontario.ca31

Dietitian Referral Form (Optional)Name of Resident:Room No. :Request Date:Request By:Intake Issues: Significant change from usual pattern in food/fluid for two ofthe three meals over a period of seven days Refusal to eat (> 3 consecutive meals) Leaves 25% or more of food for two of the three meals over aperiod of seven days Leaves 25% or more of fluid for two of the three meals over aperiod of seven daysTemporary or Permanent Diet Changes for: Fluid consistency Therapeutic diet Texture Enteral feeding SupplementOther Risks Identified by Nutrition Manager or Nursing Staff: Intake from one of the four food groups restricted (Vegetablesand Fruits, Grain Products, Meat and Alternatives, Milk andAlternatives) Change in self feeding ability Moderate to high nutrition risk findingsMedical Conditions/Symptoms: Altered skin integrity (not rashes or bruises) Aspiration pneumonia (diagnosed by the Physician) Change in health status with nutritional implications (e.g. CVA,anemia, depression, colostomy, Crohn’s disease, gastric reflux) Return from hospital with nutritional implications or significantchanges in health status Chronic urinary tract infections History of constipation or altered bowel pattern (e.g. constipationor diarrhea) Difficulty chewing or swallowing (i.e. coughing, choking,pocketing) Food related allergies or intolerances Episodes of hyper/hypoglycemia Abnormal laboratory values (deviation from resident’s normalpattern) Newly diagnosed diabetics or residents who are newly prescribedinsulin Newly diagnosed metabolic conditions that affect nutrition orhydration (e.g. kidney disease, COPD, liver failure, CHF) Palliative care Physical signs of malnutritionFor Information: 416.327.7625 32ltchrai@ontario.ca32

New triggered RAPs affecting nutritional intake: (pleasecircle)• Nutritional Status• Feeding Tubes• Dehydration/Fluid Maintenance• Dental Care• Pressure Ulcers RAI-MDS 2.0 outputs affecting nutritional intake:(please circle)• ADL changes that affect eating (G1ha),• Depression Rating Scale (DRS) affecting eating• Cognitive Performance Scale (CPS) affecting eating• Changes in Health End Stage Disease and Signsand Symptoms (CHESS) with changes in:- Vomiting - (J1o)- Dehydration - (J1c)- Leaving food uneaten - (K4c)- Weight loss - (K3a) Quality indicators affecting nutritional intake: (pleasecircle)• Prevalence of depression affecting eating• Incidence of cognitive impairment affecting eating• Prevalence of fecal impaction• Prevalence of weight loss• Prevalence of dehydration• Prevalence of tube feeding• Prevalence of stage 1-4 pressure ulcers Low body weight Unplanned gradual weight loss below goal weight range Undesirable, unplanned, progressive weight change (>5%in one month, >7.5% in 3 months and >10% in 6 monthsto one year) Signs and symptoms of dehydration Vomiting and/or diarrhea lasting more than 72 hours Dental issues affecting nutrition intake (e.g. mouth pain,broken or loose teeth) Other________________________________________________________________________________________________________________________________________Checklist Received By:Name: _________________________(Please print)Signature: __________________________Title: _________________________Date: _________________________For Information: 416.327.7625 33ltchrai@ontario.ca33

Resident Assessment Protocol (RAP) Auditing Tool – OptionalResident Name:______________ Unit: ______________ Type of Assessment: _________________Criteria to Review1. Completion of the Section V: RAP Summary Form. Present NotPresentA. Column (a), check if triggered (this may be checked by the softwareautomatically)B. Location and date of the current RAP assessment documentation(references to various locations in the chart such as: consultation notes,M.D. orders and notes, therapy notes, nurses’ notes etc.)PartialC. Column (b), check if RAPs documentation indicates that care planning isrequiredD. Signature of RN/RPN at VB1E. Date of VB2 (Completion of RAPs)F. Signature at VB3G. Date of VB4 (Completion of the Care Plan, Vb3+Vb4)2. Accurate Timing of RAP and care plan completion:In Section V: Resident Assessment Protocol Summary formA. VB2: for quarterly, annual and significant change: ARD + 7 daysVB2: for new admission: AB1a (Admission Date) + 14 days or ARD + 7daysB. VB4: for quarterly, annual and significant change: ARD + 14 daysVB4: for new admission: AB1a (Admission Date) + 21 days or ARD +14 days3. RAP Assessment Summary ReviewA Use of the 5-steps template by interdisciplinary team membersB Evidence of non RAPs clinical problems identifiedCDEFGType of RAP identified (new, existing or adjusted)Nature of the problem clearly stated (Identifying data thatcontribute to the assessment)Key issues that contributed to the RAP (causative factors,complications, risk factors, impact on resident’s daily functioningand effectiveness of care planning interventionsFurther assessment and or need for referrals identified. Statereason for referralCare planning decision stated (if not, state why is the RAP not aproblem for the resident)3-93For Information: 416.327.7625 34ltchrai@ontario.ca34

Criteria to Review4. Evidence of RAI Practice Requirements Implementation Present NotPresentB Where a significant change in the resident’s health status has resulted inthe completion of an interdisciplinary assessment, then theinterdisciplinary assessment may replace the quarterly assessment forthat quarter.C The RAI-MDS 2.0 assessment instrument is a primary source document: With the exception of medical diagnoses, test results or examinations,physician orders, and advanced directives, duplicate documentationis not required to support all RAI-MDS 2.0 assessment items Information comes from multiple sources: observations, review ofclinical records, plans of care, interviews with the resident, significantothers, team members RAI-MDS 2.0 assessment and RAI outputs identify actual andpotential resident care needs and provide the evidence on which tobase decisions relating to care planningD For quarterly RAI-MDS 2.0 assessments, the following standardstatement may be used for “existing” triggered RAPs that have no clinicaland / or care plan changes.PartialThis is an existing RAP. The resident is responding to the interventionsas outlined in the care plan. His / her clinical assessment has notchanged from the last assessment. Care plan goals and interventionshave been reviewed by the care team members and continue to beeffective in (preventing, improving or maintaining) the RAP problem.EF For significant change in status assessments that do not take theplace of the full annual assessment, the standard statement may beused For the initial admission and annual full assessments, no standardstatement will be used for existing RAPsOnce a year, all RAPs must be reviewed and treated as new and nostandard statement may be usedThe RAPs assessment summaries and plan of care for triggered RAPsmay be combined if the goals of care, risk factors, care interventions, andtreatments are all interrelated.The use of other assessment tools, in addition to RAI-MDS 2.0 shouldonly be necessary following the RAI-MDS 2.0 assessment and ResidentAssessment Protocols (RAPs) analysis when clinicians, based on theirclinical judgment, make a decision to make a referral and/or conductfurther assessment for the development of a comprehensive residentplan of care.5 Linkage of Care Plan Interventions to RAPs AssessmentSummariesA Evidence of plan of care interventions reflecting the RAPs triggersB Evidence of referral follow upC Evidence of ongoing care plan interventions evaluationFor Information: 416.327.7625 35ltchrai@ontario.ca35

CHAPTER 4: RAI-MDS 2.0 Outputs and ReportsCHAPTER 4: RAI-MDS 2.0 Outputs and Reports .................................. 1Overview .............................................................................................. 2Strategies for Implementation of RAI Outputs and Reports ............. 13Preparing for RAI-MDS 2.0 Outputs and Reports Checklist .............. 14RAI-MDS 2.0 Outputs Software Orientation Checklist ...................... 15Application of RAI-MDS 2.0 Reports to Quality Improvement Plan .. 16Case Study Application...................................................................... 18References ......................................................................................... 25InterRAI RAI-MDS 2.0 Quality Indicator Definitions............................................................................................26

OverviewOVERVIEW• Getting started with RAI-MDS 2.0 outputs implementation• Benefits of RAI-MDS 2.0 outputs and reports• Quality indicators: definition, type, risk adjustment, interpretation• Quality Scales/Measures: measurement and interpretation• Resource utilization groups: definition and case mix index• Strategies for Implementation of RAI-MDS 2.0 Outputs and ReportsINTRODUCTIONIndividual home policy will determine what RAI-MDS 2.0 output reports that the dietician and nutrition manager willaccess as read only. Calculation of the RAI-MDS 2.0 outputs will not be presented. You may contact your home’sRAI Coordinator for a more detailed RAI-MDS 2.0 output calculation information.GETTING STARTED WITH RAI-MDS 2.0 OUTPUTS IMPLEMENTATION• Review the RAI-MDS 2.0 outputs and reports chapter in the RAI-MDS 2.0 Nutrition Care Resource Guide• Implement the “RAI-MDS 2.0 Outputs and Reports Implementation To Do Checklist” in the resource guideRAI-MDS 2.0 OUTPUT REPORTS - FROM HOME SOFTWAREFollowing the completion of RAI-MDS 2.0 assessment, several RAI-MDS 2.0 output reports can be generatedautomatically from the computer:• Quality Indicators (QIs)• Outcome Measures/Scales• Resource Utilization Groups (RUGs)RAI-MDS 2.0 OUTPUT REPORTS - FROM CIHI• Home Administrator, Director of Care and the RAI Coordinator have access to CIHI quarterly provincialcomparative report.• These reports are generally available around Sep. 25, Dec. 20, Mar. 25 and Jun. 25.BENEFITS OF RAI-MDS 2.0 REPORTS - QUALITY INDICATORS AND OUTCOME SCALESAt the resident level, RAI-MDS 2.0 reports help to improve clinical practice by:• Identifying resident care needs• Supporting the RAPs documentation• Enabling the development of a focused care plan• Tracking resident-specific outcomes• Monitoring resident change over time• Prioritizing quality improvement activities• Targeting for specific clinical trainingFor Information: 416.327.7625 2ltchrai@ontario.ca2

QUALITY INDICATORSWHAT ARE QUALITY INDICATORS (QIS)?• Flag potential nutritional concerns to identify possible additional assessment or intervention needs• Embedded in the RAI-MDS 2.0, there are 35 QIs covering 11 domains of care• Depending on the individual home policy, other indicators may be tracked for clinical or operationalpurposes (e.g. renal and gluten free diets, insulin dependent residents, nutritional supplements)Early Generation: 24 quality indicators• Representing 11 domainsNew Continuing Care Reporting System (CCRS) QI’s:• Including 35 quality indicators representing 15 domains with:¯ new measures of pain, delirium, communications and infections¯ new focus on outcomes of various conditions¯ new risk adjustments enhance comparison abilities; and¯ better reflection of clinical complexity and resident functionRAI-MDS 2.0 QUALITY INDICATORSDomainQuality IndicatorsPHYSICAL FUNCTIONActivities of Daily LivingMobilityWorsened early-loss ADL; improvedWorsened mid-loss ADL; improvedWorsened late-loss ADL; improvedWorsened ADLWorsened locomotionImproved locomotionPSYCHOSOCIAL FUNCTIONBehaviourCognitive FunctionCommunicationDeliriumWorsened behavioural symptomsImproved behavioural symptomsWorsened cognitive abilityImproved cognitive abilityWorsened communication abilityImproved cognitive abilityHas deliriumFor Information: 416.327.7625 3ltchrai@ontario.ca3

MoodWorsened mood – symptoms of depressionSAFETYMedicationsFallsInfectionsTaken antipsychotics without a relevant diagnosisFallen (in last 30 days)Has an infectionWorsened/unchanged respiratory infectionPressure Ulcers Has a pressure ulcer at stages 2 to 4Worsened pressure ulcer at stages 2 to 4Has a new pressure ulcer at stages 2 to 4RestraintsDaily physical restraintsOTHER CLINICAL ISSUESContinenceNutrition/WeightPainHas an indwelling catheterHas urinary tract infectionImproved bowel continence; worsenedImproved bladder continence worsenedHas a feeding tubeHas had weight lossHas painWorsened painQUALITY INDICATORS (QI) FOR NUTRITION CARE TEAMThe most common quality indicators that the nutrition care team reviews or contributes to are:• Has a feeding tube feeding Has a pressure ulcer at stages 2 to 4 Worsened pressure ulcer at stages 2 to 4 Has a new pressure ulcer at stages 2 to 4• Has had weight loss• Has urinary tract infectionOther QIs that may be relevant for the nutrition care team to review are: worsened behavioural symptoms, worsenedmood – symptoms of depression, worsened cognitive impairment, worsened cognitive ability, has delirium.QI CALCULATIONQIs are calculated as the percentage of residents with the QI present. It is calculated by dividing the numerator by thedenominator.Numerator (on the top):• The number of residents that have the specific characteristic / trait of that QIFor Information: 416.327.7625 4ltchrai@ontario.ca4

Denominator (on the bottom):• The total number of all residents that could have the specific characteristic / trait of that QI• Example: 18 residents who trigger the use of physical restraints indicator among 100 residents who areassessed during the most recent assessment gives an indicator rate of 18%RISK ADJUSTMENTUnderlying factors that predispose individuals to higher rate of potential quality problems that are beyond the controlof the home, and that may be unevenly distributed among homes (e.g. dementia and aggressive behaviour).Argument to adjust…Comparisons can be made more fairly among homes without penalizing homes with challenging residentsArgument not to adjust..Potential to explain away bad practiceQI INTERPRETATIONIt is helpful to have the RAI-MDS 2.0 quality indicator definitions available when interpreting the QI results.QI INTERPRETATION: STATISTICAL TERMSMean – AverageMedian - The midpoint in a series of numbers; half the data values are above the median, and half are belowPercentile - A value on the scale of 100 that indicates the percent of a distribution that is equal to or below it25th percentile - 25% of the data are smaller and 75% of the data are larger (e.g. if your home is in the 25thpercentile for prevalence of dehydration, this means that 75% of all the homes have equal or more dehydration thanyour home)75th percentile - 75% of the data are smaller and 25% of the data are larger (e.g. if your home is in the 75thpercentile for prevalence of weight loss, this means that 75% of all the homes have equal or fewer residents withweight loss than your home)SEE END OF THIS CHAPTER FOR RAI-MDS 2.0 NEW GENERATION QUALITY INDICATOR DEFINITIONSCompliance Key RAI-MDS 2.0 Risk Indicators1. Prevalence of new pressure ulcers2. Prevalence of worsening pressure ulcers3. Prevalence of daily physical restraint4. Prevalence of weight loss5. Prevalence of indwelling catheters6. Prevalence of bladder or bowel incontinence - low risk7. Incidence of worsening bowel and bladder continence - high and low8. Prevalence of moderate to severe pain9. Incidence of worsening pain10. Prevalence of falls11. Prevalence of pneumonia12. Prevalence of urinary tract infections13. Prevalence of wound infection14. Incidence of new fracturesFor Information: 416.327.7625 5ltchrai@ontario.ca5

15. Prevalence of depression without anti-depressant therapy16. Incidence of worsening depression or anxiety17. Prevalence of behavioural symptoms affecting others - high & low18. Incidence of worsening resident behavior19. Incidence of worsening function in daily activities20. Prevalence of antipsychotic drug use in the absence of psychotic and related conditions - high & low21. Prevalence of anti-anxiety/hypnotic drug use22. Prevalence of hypnotic drug use more than two days in past week23. Prevalence of fecal impactionQIs for Ontario Health Quality Council1. Incidence of worsening of bladder incontinence **2. Prevalence of depression without anti-depressant therapy3. Prevalence of anti-anxiety/hypnotic drug use4. Incidence of worsening depression5. Incidence of residents whose cognitive functioning improved since last assessment6. Incidence of residents whose cognitive functioning declined since last assessment7. Prevalence of weight loss8. Incidence of worsening function in daily activities using the long form (global measure including eating,moving in bed, locomotion, dressing and personal hygiene etc)9. Incidence of residents with some worsening of ADL using the mid-loss (locomotion, transfer and walk incorridor)10. Prevalence of moderate to severe pain11. Incidence of worsening pain12. Prevalence of indwelling catheters13. Prevalence of urinary tract infections14. Prevalence of worsening pressure ulcers (stage 2 to 4)**15. Incidence of stage 2-4 pressure ulcers **16. Incidence of fall in the past 30 days prior to assessment**17. Prevalence of daily physical restraint18. Prevalence of restraints use at least once over past 7 days19. Prevalence of antipsychotic drug use in the absence of psychotic and related conditions (schizophrenia orother psychosis)20. Prevalence of behavioural symptoms affecting others (verbal, physical, socially inappropriate)21. Incidence of worsening resident behavior** This was reported at facility level in the Public Reporting 2009, ‘Long-Term Care in Ontario: A report onquality’www.ohqc.caRAI-MDS 2.0 Indicators for LHIN Service Accountability Agreement (L-SAA)• Prevalence of worsening pressure ulcers• Incidence of new pressure ulcers (stage 2-4)• Prevalence of daily physical restraint• Incidence of worsening bladder incontinence• Incidence of new fractures• Incidence of fallsFor Information: 416.327.7625 6ltchrai@ontario.ca6

OUTCOME SCALES/MEASURESOUTCOME SCALES1. ADL Scales (ADL Self Performance)a) - ADL Self Performance Hierarchy Scaleb) - ADL Short Formc) - ADL Long Form2. Depression Rating Scale (DRS) (Level of Depression)3. Pain Scale (Prevalence of Pain)4. Cognitive Performance Scale (CPS) (Level of Cognition)5. Changes in Health, End Stage Disease, Signs and Symptoms (CHESS) Scale (Frailty and instability)6. Index of Social Engagement (Degree of Social Engagement)7. interRAI Pressure Ulcer Risk (Pressure Ulcer Risk)8. Aggressive Behaviour Scale (Aggressive Behaviour)ACTIVITIES OF DAILY LIVING SCALESUses Information from RAI-MDS 2.0 Section GScale Measurement Score InterpretationADL Self-PerformanceHierarchy Scale• Personal Hygiene• Toileting• Locomotion On Unit• EatingADL Short Form • Personal Hygiene (G1jA)• Toilet Use (G1iA)• Locomotion on Unit (G1eA)• Eating (G1hA)ADL Long Form • Bed Mobility (G1aA)• Transfers (G1bA)• Locomotion on unit (G1eA)• Dressing (G1gA)• Eating (G1hA)• Toilet Use (G1iA)• Personal Hygiene (G1jA)0 - 6 Higher scores indicate moreimpairment0 -16 Higher scores indicate moreimpairment0 - 28 Higher scores indicate moreimpairmentADL Scales (3) Candidate for replacement of Barthel, Katz and FIM toolsDEPRESSION RATING SCALE (DRS)Based on the summation of 7 mood items from Section E1(Indicators of Depression, Anxiety, Sad Mood)• E1a - Resident made negative statements• E1d - Persistent anger with self or others• E1f - Expressions what appear to be unrealistic fears• E1h - Repetitive health complaints• E1i - Repetitive anxious complaintsFor Information: 416.327.7625 7ltchrai@ontario.ca7

• E1l - Sad, pained worried facial expressions• E1m - Crying, tearfulnessUsed as a clinical screen for detecting depressionDEPRESSION RATING SCALE• Scores range from 0 to 14• A score of 3 or greater suggests possible depression• If depression indicated on DRS (>3), further investigation is suggested• Validated against the Hamilton Depression Rating Scale and the Cornell Scale for DepressionPAIN SCALE• Uses two RAI-MDS 2.0 items for calculation (J2a and J2b)• Score ranges from 0 - 3• Has shown to be highly predictive of pain on the Visual Analogue ScaleScore Description RAI-MDS 2.0 Item0 No Pain J2a=01 Less than daily pain J2a=12 Daily pain, but not severe J2a=2 AND J2b=1 or 23 Severe daily pain J2a=2 AND J2b=3COGNITIVE PERFORMANCE SCALE (CPS)• Based on 5 items from section B, C and G of the RAI-MDS 2.0- B1 - Comatose (B1)- B2a - Short-term memory (B2a)- B4 - Cognitive skills for daily decision-making- C4 - Making self understood- G1hA - Eating - differentiates between a score of 5 or 6 on the CPS Scale• Measures a resident’s level of cognition• Validated against the Mini-Mental State Examination (MMSE) and the Test for Severe Impairment• Scores range from 0 - 6• Higher score indicate greater cognitive impairmentCPS AND MMSE COMPARISONThere is a strong correlation between CPS and MMSEFor Information: 416.327.7625 8ltchrai@ontario.ca8

CPS Score Description MMSE(average)0 Intact 251 Borderline intact 222 Mild impairment 193 Moderate impairment 154 Moderate/severe impairment 75 Severe impairment 56 Very severe impairment 1CHANGES IN HEALTH, END-STAGE DISEASE AND SIGNS AND SYMPTOMS (CHESS SCALE)• Based on the calculation of 9 RAI-MDS 2.0 © items in sections J, K, B and G:- J1o - Vomiting- J1c - Dehydration- K4c - Leaving food uneaten- K3a - Weight loss- J1l - SOB- J1g - Edema- J5c - End stage disease- B6 - Decline in cognition- G9 - Decline in ADL• Detects frailty and instability of health, identifies residents at risk of serious decline. Proven to be a strongpredictor of mortality• Maximum score is 5. Higher scores are associated with reduction in survival over timeHirdes et al (2003) JAGS,51, 96-100INDEX OF SOCIAL ENGAGEMENT• Based on the summation of 6 RAI-MDS 2.0 items on Section F:- F1a - At ease interacting with others- F1b- At ease doing planned or structured activities- F1c - At ease doing self-initiated activities- F1d - Establishes own goals- F1e - Pursues involvement in the life of the facility- F1f - Accepts invitations into most group activities• Score ranges from 0 - 6• Highly correlated with actual time spent in activities• Higher number indicates increased engagementMor, et al (1995). J. Gerontol. 50(1), P1-P8For Information: 416.327.7625 9ltchrai@ontario.ca9

AGGRESSIVE BEHAVIOUR SCALE (ABS)• Based on the summation of 4 items from Section E4- Physical abuse (E4c)- Verbal abuse (E4b)- Socially inappropriate (E4d)- Resisting care (E4e)• Scores range from 0 to 12• High score represents greater frequency and intensity of behaviourinterRAI PRESSURE ULCER RISK Based on the summation of 7items from the RAI-MDS 2.0 assessment1. bowel incontinence2. bed mobility self-performance3. walk in room self-performance4. weight loss5. history of resolved ulcer6. daily pain7. shortness of breath Scores range from 0 to 8 Was validated against the Braden Scale for Predicting Pressure Ulcer Risk High score represents greater risk of a pressure ulcerEXAMPLE OF A RESIDENT OUTCOMES REPORTAssessment CPS DRS PAIN CHESS ADLShortMAdmissionr2nd assessments3rd assessment4th assessmentLRange22220-6118330-1432100-311310-5481070-16ADLLong61622130-28ADLHierarchyISE ABS PURS1 1 0 12 2 0 45 2 0 62 5 0 20-60-60-120-8Depending on Home software, Outcome reports can be summarized by resident, unit/program and facility levelFor Information: 416.327.7625 10ltchrai@ontario.ca10

RESOURCE UTILIZATION GROUPS (RUG III)BENEFITS OF RUG REPORT• Comparing resident profile, resource requirements and utilization• Trending resource intensity over time to validate workloadRESOURCE UTILIZATION GROUPS RUG-IIIUpon completion of the RAI-MDS 2.0 assessment, residents are grouped into one of the 7 major groups based ontheir clinical and diagnostic characteristics and resource utilization:• Special Rehabilitation• Extensive Services• Special Care• Clinically Complex• Impaired Cognition• Behaviourial Problems• Reduced Physical FunctioningSPECIAL REHABILITATIONResident needs therapy services to qualify• Based on types and minutes of 3 therapies - OT, PT, and SLP• Amount of Nursing Rehabilitation• ADL Score 4 -18EXTENSIVE SERVICESResident receives one or more of the following:• K5a (Parenteral / IV) is checked• P1ac (IV Medications) is checked• P1ai (Suctioning) is checked• P1aj (Tracheotomy) is checked• P1al (Ventilators) is checked• ADL Score 7-18SPECIAL CAREThe resident has one or more conditions coded such as:• Quadriplegia, Cerebral Palsy or Multiple Sclerosis• Radiation• Feeding tube and Aphasia• Fever with one of either dehydration, vomiting, weight loss, pneumonia or feeding tube• Surgical wounds, open lesions and skin treatments• Ulcers and Skin Treatments• Respiratory therapy• Septicemia• ADL Score 7-18CLINICALLY COMPLEX• The resident has one or more conditions coded such as:• Coma; diabetes and injections and MD orders >= 2For Information: 416.327.7625 11ltchrai@ontario.ca11

• Hemiplegia, pneumonia, septicemia, dehydration, internal bleeding, tube feeding or burns• Infections of foot, open lesions on foot, and foot dressings• Chemotherapy, dialysis, oxygen or transfusions• End stage disease• Physician visits>= 1day and order changes >= 4 OR• Physician visits >= 2 and order changes >= 2• ADL Score 4 -18• Indicators of depression, anxiety, sad moodIMPAIRED COGNITION• The Cognitive Performance Scale >= 3• Nursing Rehabilitation/Restorative Care activities (at least 2) coded for15 mins/day for 6 days. This includesP3a-j (Nursing rehabilitation/restorative care) and H3a and/or H3b (toileting plan and bladder retraining)• ADL score 4 -10BEHAVIOUR PROBLEMS• One of the following conditions are coded: wandering, verbally abusive, physically abusive, sociallyinappropriate, resists care, delusions or hallucinations• Nursing Rehabilitation/Restorative Care activities (at least 2) coded for15 mins/day for 6 days. Includes P3a-jand H3a and/or H3b (toileting plan and bladder retraining)• ADL score 4 - 10REDUCED PHYSICAL FUNCTION• Nursing Rehabilitation/Restorative Care activities (at least 2) coded for 15 mins/day for 6 days. Includes P3a-jand H3a and/or H3b (Toileting plan and bladder retraining)• ADL score 4 -18RUG-III CASE MIX INDEX (CMI)• A CMI is a value reflecting the daily relative weight of resources used by a resident within each RUG-III groupcompared to a base resource level (average)• RUG-III CMI is not a dollar value• It establishes the relative weights for residents within each RUG-III group• The CMI values are derived so that the “average resident” has a CMI value of 1• It can then be determined how much more or less than the average a resident may costRUG-III CMI• A CMI of 1.2 for a resident indicates that this resident requires approximately 20% more resources than theaverage resident• A CMI of 0.9 indicates that this resident requires approximately 10% less resources than the average residentFor Information: 416.327.7625 12ltchrai@ontario.ca12

Strategies for Implementation of RAI Outputsand ReportsVALIDATION OF RAI-MDS 2.0 OUTPUT REPORTSUpon receiving the home RAI-MDS 2.0 output report, it is important to validate some of the information. Forexample:• Does the number of residents with weight loss (in the numerator) seem right to you? Or the number ofresidents with fecal impaction?• The unit with the most diabetic or tube feeding residents, what is the RUG for that unit? (should be specialcare or clinically complex groups)If you are receiving RAI-MDS 2.0 output report from CIHI:• Validate the number and rate of a few quality indicators from CIHI quarterly reports with the number and rateof the same indicators generated by your home RAI-MDS 2.0 software (are the number matching up?)Notify the RAI Coordinator immediately if there is any discrepancyIMPLEMENTATION OF RAI-MDS 2.0 REPORT• Meet with management and/or the RAI Coordinator to determine who, when, how and what to share related tothe home RAI-MDS 2.0 output reports and CIHI reports• Attend training• Depending on home policy, print sample of home RAI-MDS 2.0 output reports to review, discuss and practice• Validate the reports• Incorporate RAI-MDS 2.0 output results into RAP or non-triggered RAP documentation and development of careplan interventions• Meet with management or the RAI Coordinator or CQI committee to determine which nutrition care qualityindicators to monitor and trend - select one or two indicators to start• Communicate RAI-MDS 2.0 report results to dietary team members• Link the indicator improvement with the home CQI program - Involve team members in discussion anddevelopment of an improvement plan• Celebrate progress and improvement!For Information: 416.327.7625 13ltchrai@ontario.ca13

Preparing for RAI-MDS 2.0 Outputs and ReportsChecklistThe following checklist summarizes the important tasks for the nutrition care team to review and or implement forRAI-MDS 2.0 outputs and reportsCompletionAction ItemDateMeet with RAI Coordinator to discuss:- roles and responsibilities of dietitian and nutrition manager related to RAI-MDS 2.0 outputs andreports- the type of reports for the nutrition care team- report generation - who will be responsible for printing the RAI-MDS 2.0 reports, when, how often,who will review, interpret and correct errors- regular care team conference to review and interpret RAI-MDS 2.0 outputs and reports for clinicalimprovementSet a training date and time with the RAI Coordinator for:- RAI-MDS 2.0 outputs and reports- RAI-MDS 2.0 reports softwareDepending on your home’s policy, obtain software access password for RAI-MDS 2.0 reports (readonly access).Determine who, from the food service department, will attend the training.Access and print the RAI-MDS 2.0 outputs and reports chapter from the Nutrition Care ResourceGuideAttend training for:- RAI-MDS 2.0 outputs and reports- RAI-MDS 2.0 software (don’t forget to take the RAI-MDS 2.0 Outputs and Reports SoftwareOrientation Checklist to training)Practice and print samples of RAI-MDS 2.0 output reports - by resident, unit, program and entirefacility for self-learning and training, if applicable.Identify a few nutrition care related RAI-MDS 2.0 quality indicators for CQI monitoring, share trendingand results with the care team and develop action plan for improvement, if applicable.For Information: 416.327.7625 14ltchrai@ontario.ca14

RAI-MDS 2.0 Outputs Software OrientationChecklistThis checklist will serve as a guide for dietitians and nutrition managers during their RAI-MDS 2.0 outputsand reports software orientation. Please feel free to add other checklist items specific to your software. Atthe end of your software orientation, you should be competent in performing the following computer skills.Skills Checklist Notes/Comments Check1.2.3.4.5.6.Module 4 - Output ReportsLog in and open the RAI-MDS 2.0 outputs and reportssoftware folderObtain password for RAI-MDS 2.0 output reports if applicableOpen and close RAI-MDS 2.0 output reportsAccess and view different RAI-MDS 2.0 output reports (readonly) in the software:• Cognitive Performance Scale• Depression Rating Scale• Changes in Health End Stage Disease and Signs andSymptoms (CHESS)• Pain Scale• Index of Social Engagement• ADL - Short, Long and Hierarchy scale• Aggressive Behaviour Scale• interRAI Pressure Ulcer Risk• Quality Indicators• Resource Utilization GroupsAccess and view previous RAI-MDS 2.0 output reportsPrint RAI-MDS 2.0 Output Reports by:• Resident• Unit/program• Entire facility• QuarterlyFor Information: 416.327.7625 15ltchrai@ontario.ca15

Application of RAI-MDS 2.0 Reports to QualityImprovement PlanThe quality indicator (QI) reports for Unit 1 and Unit 2 are compared. Unit 2 has more residents with weight loss thanUnit 1. In the last quarter, there were 21% of residents on Unit 2 with weight loss compared to no weight loss on Unit1 for the past two quarters.Before addressing the weight loss issue on Unit 2, it is important to validate the problem by conducting a thoroughreview of the root cause related to weight loss. Below, you will find sample questions that can be asked during theinvestigation:Step 1: Data accuracy review (records review and staff interview)• Are there any RAI-MDS 2.0 coding errors on both units?• Are supporting documentation records accurate and current? For example, the weight loss record, food andfluid intake records progress notes etc.• Are care plans up to date addressing nutrition care issues• Are there regular coding accuracy checks? When was the last coding accuracy check conducted? Whatwas the result?Step 2: Other related quality indicators (to weight loss) review• A review of other QIs related to weight loss, for example:- Prevalence of symptoms of depression- Prevalence of symptoms of depression without antidepressant therapy- Prevalence of the use of nine or more different medications- Incidence of cognitive impairment- Prevalence of fecal impaction- Prevalence of tube feeding- Prevalence of dehydration- Incidence of decline in ROM- Prevalence of antipsychotic drug use in the absence of psychotic and related conditions- Prevalence of anti-anxiety/hypnotic drug use- Prevalence of hypnotic drug use more than two days in past week- Prevalence of Stage 1-4 pressure ulcers- Prevalence of little or no activityStep 3: Resident profile review (between the 2 units)• A review of RAPs related to weight loss, for example:- Nutritional Status- Feeding Tubes- Dehydration/Fluid Maintenance Status- Dental CareFor Information: 416.327.7625 16ltchrai@ontario.ca16

• A review of the RUG III groups, for example:- What is the general resident profile on each unit?- Are there more residents in Unit 2 in the ‘special care’ or ‘clinically complex’ groups? (e.g. more diabeticand tube feeding residents on Unit 2)• A review of the RAI-MDS 2.0 outcome measures, for example:- What is the CHESS Scale score for both units? Higher CHESS score means higher frailty and instabilityof health- What are the Cognitive Performance Scale (CPS) scores? Are there more cognitively impairedresidents on Unit 2?- What are the Depression Rating Scale (CPS) scores for both units?- For the Pain and Index of Social Engagement Scale scores, are there any differences between the twounits?Step 4: Other potential contributing factors reviewCare Practice (staff interview, observation, care team conference)• Are residents receiving nourishments and other supplements as ordered on both units?• Are the weight scales properly calibrated on both units?• Are residents being weighed according to home protocols on both units?• Are staff following the dietitian referral protocol and making referrals when appropriate?Other (management reporting)• What is the staff turnover or staffing on both units? (Is Unit 2 having more staff turnover and staff shortage?This may impact coding accuracy or continuing of care)• Are staff members familiar with RAI-MDS 2.0 coding and RAPs documentation?Step 5: Data analysis: identification of potential contributing factors to weight loss• Review data collected from above and identify possible contributing factors to weight loss on Unit 2Step 6: Quality improvement plan development• Communicate results of the investigation to the care team• Collaborate with team members, including PSWs, to establish short and long term goals and developstrategies addressing weight loss on Unit 2• Identify if training is required• Document interventions and responsible person(s) for implementation in care plans and CQI plan• Determine how to monitor the interventions to ensure that they are implemented• Set a target date for team review and evaluate its effectiveness• Communicate the plan to all shifts and the entire care team• Adjust interventions as appropriate during the implementation of the planFor Information: 416.327.7625 17ltchrai@ontario.ca17

Case Study ApplicationThe Quality Indicator reports for Unit 1 and Unit 2 were compared.It was observed by the Dietitian, in consultation with the RAI Coordinator, that the quality indicator - prevalenceof weight loss – was higher on Unit 2 than on Unit 1.This warranted an investigation to determine if there is a quality of care issue.Step 1: The quality of the data was examined.• Coding was found to be correct on the relevant RAI-MDS 2.0 assessments• The weigh scales were correctly calibrated• Residents were being weighed according to facility protocolStep 2 and 3: Examination of other Quality Indicators related to weight loss• There was a higher prevalence of depression on Unit 2• There were no residents on tube feeding on Unit 2• There were no residents with fecal impaction in Unit 2Step 4 and 5: Other contributing factors review and data analysisThe individual residents who had lost weight were identified and investigated.• After drilling down and examining the weight loss records and food and fluid intake records, it was found thatthere was a quality improvement opportunity on Unit 2.• Two of the residents who had lost weight on Unit 2 were on pureed diets secondary to swallowingdifficulties. The food and fluid records indicated that these residents were consuming all of the food at eachof the daily meals. These two male residents were usually sleeping when the evening snack was passed,thus, not consuming the snack.• The Pureed Meal Plan for the LTC home includes a snack in the evening that is an important contributor tothe residents’ energy and protein intake.• It was determined that the probable cause for the weight loss in these two residents was that they were notconsuming their evening snack. Energy intake was inadequate.• The Depression Rating Scales for these residents indicated that they would benefit from treatment fordepression. Untreated depression may be related to the reason that they were going to bed early.Quality Improvement Plan:1. A referral was made to the physician to assess whether the residents might benefit from anti-depressanttherapy and/or medication.2. The Dietitian revised the care plan for each resident. Each of these residents now receives an afternoonsnack containing enough calories, protein and micronutrients to ensure that they are meeting their nutrientneeds. In addition, she/he investigated if this was a concern for other residents on the pureed diet thenperhaps the Pureed Meal Plan for the home should be changed.3. The residents were to be weighed on a weekly basis to see if weight stabilization/gain was occurring.4. The proposed solution to change the provision of the supplement to the afternoon nourishment pass (afterresidents had awakened from afternoon nap), and residents to be weighed weekly would be reassessedafter one month. The RD will monitor each resident’s weight weekly.For Information: 416.327.7625 18ltchrai@ontario.ca4-3018

Domain # Quality Indicators – Unit One Fiscal QuarterAccidents April-June 07 July-Sept 07 Oct-Dec 07 Jan-March 0812Incidence of new fracturesNumerator 0 1 0 0Denominator 15 20 18 20Prevalence 0 % 5 % 0 % 0 %Prevalence of fallsNumerator 6 7 5 2Denominator 16 20 19 20Prevalence 37.5 % 35 % 26.3 % 10 %Behavior/Emotional Patterns3 Prevalence of behavioral symptoms affecting othersAllNumerator 11 12 13 13Denominator 16 20 19 20Prevalence 68.8 % 60 % 68.4 % 65%Low riskNumerator 0 1 1 0Denominator 0 1 1 0Prevalence 0 % 100 % 100 % 0 %High riskNumerator 11 11 12 13Denominator 16 19 18 20Prevalence 68.8 % 57.9 % 66.7 % 65 %4 Prevalence of symptoms of depressionNumerator 7 11 8 8Denominator 16 20 19 20Prevalence 43.8 % 55 % 42.1 % 40 %5 Prevalence of symptoms of depression withoutantidepressant therapyNumerator 1 1 0 1Denominator 16 20 19 20Prevalence 6.3 % 5 % 0 % 5 %Clinical Management6 Use of 9 or more different medicationsNumerator 12 14 14 15Denominator 16 20 19 20Prevalence 75 % 70 % 73.7 % 75 %Cognitive Patterns7 Incidence of cognitive impairmentNumerator 16 19 19 20Denominator 16 20 19 20Prevalence 100 % 95 % 100 % 100 %Elimination/Incontinence8 Prevalence of bladder or bowel incontinenceAllNumerator 11 13 14 13Denominator 16 20 19 19Prevalence 68.8 % 65 % 73.7 % 68.4 %Low riskNumerator 6 5 6 5Denominator 7 12 11 10For Information: 416.327.7625 19ltchrai@ontario.ca19

Domain # Quality Indicators – Unit One Fiscal Quarter9101112Prevalence 85.7 % 41.7 % 54.5 % 50 %High riskNumerator 5 8 8 8Denominator 9 8 8 9Prevalence 55.6 % 100 % 100 % 88.9 %Prevalence of occasional or frequent bladder orbowel incontinence without a toileting planNumerator 3 6 4 3Denominator 9 13 13 10Prevalence 33.3% 46.2 % 30.8 % 30 %Prevalence of indwelling catheterNumerator 0 0 0 1Denominator 16 20 19 20Prevalence 0 % 0 % 0 % 5 %Prevalence of fecal impactionNumerator 0 0 0 0Denominator 16 20 19 20Prevalence 0 % 0 % 0 % 0 %Prevalence of urinary tract infectionsNumerator 0 0 0 0Denominator 16 20 19 20Prevalence 0 % 0 % 0 % 0 %13 Prevalence of weight lossNumerator 2 1 0 0Denominator 16 20 19 20Prevalence 12.5 % 5 % 0 % 0 %14 Prevalence of tube feedingNumerator 2 2 2 2Denominator 16 20 19 20Prevalence 12.5 % 10 % 10.5 % 10 %15 Prevalence of dehydrationNumerator 0 0 0 0Denominator 16 20 19 20Prevalence 0% 0 % 0 % 0 %Physical Functioning16 Prevalence of bedfast residentsNumerator 0 0 0 0Denominator 16 20 19 20Prevalence 0 % 0 % 0 % 0 %17 Incidence of declining in late loss ADLsNumerator 5 4 5 3Denominator 13 17 16 17Prevalence 38.5 % 23.5 % 31.3 % 17.6 %18 Incidence of declining in ROMNumerator 0 0 0 0Denominator 16 20 19 20Prevalence 0 % 0 % 0 % 0 %Psychotropic Drug Use19 Prevalence of antipsychotic use, in the absence ofpsychotic or related conditionsAllNumerator 11 8 9 5Denominator 14 12 10 6For Information: 416.327.7625 20ltchrai@ontario.ca20

Domain # Quality Indicators – Unit One Fiscal QuarterPrevalence 78.6 % 66.7 % 90 % 83.3 %Low RiskNumerator 5 4 6 2Denominator 5 6 7 2Quality of LifeSkin Care20212223Prevalence 100 % 66.7 % 85.7 % 100 %High RiskNumerator 6 4 3 3Denominator 9 6 3 4Prevalence 66.7 % 66.7 % 100 % 75 %Prevalence of antianxiety/hypnotic useNumerator4-321 1 0 0Denominator 14 12 10 6Prevalence 7.1 % 8.3 % 0 % 0 %Prevalence of hypnotic use more than two times inlast weekNumerator 0 0 0 0Denominator 16 20 19 20Prevalence 0 % 0 % 0 % 0 %Prevalence of daily physical restraintsNumerator 3 6 7 7Denominator 16 20 19 20Prevalence 18.8 % 30 % 36.8 % 35 %Prevalence of little or no activityNumerator 1 7 7 4Denominator 16 20 19 20Prevalence 6.3 % 35 % 36.8 % 20 %24 Prevalence of stage 1-4 pressure ulcersAllNumerator 2 4 2 1Denominator 16 20 19 20Prevalence 12.5 % 20 % 10.5 % 5 %Low RiskNumerator 1 0 0 0Denominator 8 10 8 8Prevalence 12.5 % 0 % 0 % 0 %High RiskNumerator 1 4 2 1Denominator 8 10 11 12Prevalence 12.5 % 40 % 18.2 % 8.3 %For Information: 416.327.7625 21ltchrai@ontario.ca21

Domain # Quality Indicators – Unit Two Fiscal QuarterAccidents April-June 07 July-Sept 07 Oct-Dec 07 Jan-March 0812Incidence of new fracturesNumerator 0 0 0 1Denominator 17 17 17 19Prevalence 0 % 0 % 0 % 5.3 %Prevalence of fallsNumerator 8 7 2 2Denominator 18 17 17 19Prevalence 44.4 % 41.2 % 11.8 % 10.5 %Behavior/Emotional Patterns3 Prevalence of behavioral symptoms affecting othersAllNumerator 8 10 7 11Denominator 18 17 17 19Prevalence 44.4 % 58.8 % 41.2 % 57.9 %Low riskNumerator 0 0 0 0Denominator 0 0 0 0Prevalence 0 % 0 % 0 % 0 %High riskNumerator 8 10 7 11Denominator 18 17 17 19Prevalence 44.4 % 58.8 % 41.2 % 57.9 %4 Prevalence of symptoms of depressionNumerator 11 11 9 11Denominator 18 17 17 19Prevalence 61.1 % 64.7 % 52.6 % 57.9 %5 Prevalence of symptoms of depression withoutantidepressant therapyNumerator 4 4 4 4Denominator 18 17 17 19Prevalence 22.2 % 23.5 % 23.5 % 21 %Clinical Management6 Use of 9 or more different medicationsNumerator 2 7 5 2Denominator 18 17 17 19Prevalence 11.1 % 41.2 % 29.4 % 10.5 %Cognitive Patterns7 Incidence of cognitive impairmentNumerator 14 13 14 15Denominator 18 17 17 19Prevalence 77.7 % 76.5 % 82.4 % 78.9 %Elimination/Incontinence8 Prevalence of bladder or bowel incontinenceAllNumerator 14 13 11 13Denominator 18 17 17 19Prevalence 77.8 % 76.5 % 64.7 % 68.4 %Low riskNumerator 1 1 1 3For Information: 416.327.7625 22ltchrai@ontario.ca22

Domain # Quality Indicators – Unit Two Fiscal QuarterDenominator 4 4 6 8Prevalence 25 % 25 % 16.7 % 37.5 %High riskInfection ControlNutrition/EatingPhysical FunctioningPsychotropic Drug Use9101112131415161718Numerator 13 12 10 10Denominator 14 13 11 11Prevalence 92.9 % 92.3 % 90.9 % 90.9 %Prevalence of occasional or frequent bladder orbowel incontinence without a toileting planNumerator 2 3 3 5Denominator 8 9 6 9Prevalence 25 % 33.3 % 50 % 55.6 %Prevalence of indwelling catheterNumerator 0 0 0 0Denominator 18 17 17 19Prevalence 0 % 0 % 0 % 0 %Prevalence of fecal impactionNumerator 0 0 0 0Denominator 18 17 17 19Prevalence 0 % 0 % 0 % 0 %Prevalence of urinary tract infectionsNumerator 0 0 0 0Denominator 18 17 17 19Prevalence 0 % 0 % 0 % 0 %Prevalence of weight lossNumerator 2 4 2 4Denominator 18 17 17 19Prevalence 11.1 % 23.5 % 11.8 % 21.1 %Prevalence of tube feedingNumerator 0 0 0 0Denominator 18 17 17 19Prevalence 0 % 0 % 0 % 0 %Prevalence of dehydrationNumerator 0 0 0 0Denominator 18 17 17 19Prevalence 0 % 0 % 0 % 0 %Prevalence of bedfast residentsNumerator 0 0 0 0Denominator 18 17 17 19Prevalence 0 % 0 % 0 % 0 %Incidence of declining in late loss ADLsNumerator 3 0 2 2Denominator 12 10 10 12Prevalence 25 % 0 % 20 % 16 %Incidence of declining in ROMNumerator 0 0 0 0Denominator 18 17 17 19Prevalence 0 % 0 % 0 % 0 %19 Prevalence of antipsychotic use, in the absence ofpsychotic or related conditionsFor Information: 416.327.7625 23ltchrai@ontario.ca23

4-35Domain # Quality Indicators – Unit Two Fiscal QuarterAllNumerator 7 6 4 7Denominator 16 14 11 12Quality of LifeSkin Care20212223Prevalence 43.8 % 42.9 % 36.4 % 58.3 %Low RiskNumerator 1 1 2 2Denominator 8 5 5 4Prevalence 12.5 % 20 % 40 % 50 %High RiskNumerator 6 5 2 5Denominator 8 9 6 8Prevalence 75.8 % 55.6 % 33.3 % 62.5 %Prevalence of antianxiety/hypnotic useNumerator 2 1 1 2Denominator 16 14 11 12Prevalence 12.5 % 7.1 % 9.1 % 16.7 %Prevalence of hypnotic use more than two times inlast weekNumerator 0 0 0 0Denominator 18 17 17 19Prevalence 0 % 0 % 0 % 0 %Prevalence of daily physical restraintsNumerator 8 6 4 6Denominator 18 17 17 19Prevalence 44.4 % 35.3 % 23.5 % 31.6 %Prevalence of little or no activityNumerator 7 10 7 10Denominator 18 17 17 17Prevalence 38.9 % 58.8 % 41.2 % 58.8 %24 Prevalence of stage 1-4 pressure ulcersAllNumerator 2 1 2 2Denominator 18 17 17 19Prevalence 11.1 % 5.9 % 11.8 % 10.5 %Low RiskNumerator 0 0 0 0Denominator 4 6 6 7Prevalence 0 % 0 % 0 % 0 %High RiskNumerator 2 1 2 2Denominator 14 11 11 12Prevalence 14.3 % 9.1 % 18.2 % 16.7%For Information: 416.327.7625 24ltchrai@ontario.ca4-3524

ReferencesFor Information: 416.327.7625 25ltchrai@ontario.ca25

InterRAI RAI-MDS 2.0 Quality Indicator Definitions

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CHAPTER 5: AppendicesCHAPTER 5: Appendices...................................................................... 1Strategies for Achieving RAI-MDS 2.0 Requirements in the Absence ofthe Services of a Dietitian ................................................................... 2RAI-MDS 2.0 Quality Improvement Tool for Nutrition Care ................. 4Literature: Recommended Articles ..................................................... 8

Strategies for Achieving RAI-MDS 2.0Requirements in the Absence of the Servicesof a DietitianFor homes that have been unsuccessful in their recruiting efforts of a dietitian, the following strategies are for theirnursing and nutrition manager to implement in the absence of a dietitian. During the absence of a dietitian, thenutrition manager and registered staff will need to collaborate to ensure the nutritional needs of the residents are met.These strategies may be modified and/or integrated into the home’s policy and practice. Homes in this situationshould continue their efforts in recruiting a dietitian.For Nutrition Manager:1. Set up regular meeting with the unit charge nurse or the RAI Coordinator to review residents’ nutrition carestatus and update priority residents and care plans.2. Provide a list of high-risk nutrition care residents to nursing, including residents with renal, swallowing andenteral feeding.3. Depending on home’s policy, maintain ongoing nutritional care, coding, RAP documentation and care planningfor medium to low risk residents.4. Depending on the home’s policy, review dietitian referral form with the unit charge nurse.5. Collaborate with registered staff to re-assign nutrition risk level as required.6. Participate in the interdisciplinary team care conference or RAPs and care planning review.7. Inform the RAI Coordinator of vacation or leave of absence so that RAI-MDS 2.0 assignment will be re-assignedto registered staff.8. Maintain record of all dietitian referral forms.For Nursing:1. Assign all high-risk nutrition care residents, including high priority residents (e.g. renal, swallowing, enteralfeeding etc.) to registered staff to complete coding, RAPs and care planning.2. Explore with management the availability of external dietitian resources including:• Dietitian agency services• Hospital Dietitian• Home Care Dietitian3. Assess and determine the home’s ability to meet residents’ nutritional needs prior to accepting placement.Advise CCAC and the Ministry of the home’s decision to decline a resident admission related to complex dietaryneeds and lack of on-site dietitian services.4. Residents with renal needs: contact the renal centre dietitian to ensure the necessary nutritionalrecommendations are sent back to the home to be implemented by the attending physician.5. Residents on enteral feeding: ensure prior to admission/re-admission that the resident is stable and implementformulary as recommended by the home care or hospital dietitian.6. Residents with swallowing difficulties: communicate to physician when a change in diet order is required andplace a referral to a Speech Language Pathologist for assessment and recommendations.For Information: 416.327.7625 2ltchrai@ontario.ca2

7. New admission: complete RAI-MDS 2.0 assessment, RAPs and care planning for the new admission by theregistered staff in collaboration with the nutrition manager.8. Collaborate with nutrition manager to re-assign nutrition risk level as required.9. Maintain and have available an ongoing list of priority residents requiring immediate dietitian assessment forwhen dietitian services become available.For Information: 416.327.7625 3ltchrai@ontario.ca3

RAI-MDS 2.0 Quality Improvement Tool forNutrition CareThe purpose of the RAI-MDS 2.0 Quality Improvement (QI) Tool for Nutrition Care is to support the nutrition careteam with monitoring the quality of the RAI-MDS 2.0 implementation within their own food service department.The tool can be used by the clinical dietitian as a self-assessment or by a third party for an objective review. It isrecommended that during the early years of RAI-MDS 2.0 implementation, it would be beneficial for the nutrition careteam to use this QI tool annually as an evaluation of the RAI-MDS 2.0 implementation. Results of the evaluation canbe incorporated into the annual quality improvement plan for the food service department.The outcome of successful RAI-MDS 2.0 education and implementation in the home can be measured by theimprovement in: Coordination of care Use of RAI-MDS 2.0 information for decision-making Adaptation to the RAI-MDS 2.0 change Maintenance of data completenessThis effort can be measured by the following indicators:1. Use of Clinical Information TechnologyClinical information is available electronically to care providers.2. Coordination of CareThe extent to which the team are collaborating vertically and horizontally.3. Use of Data for Decision-MakingHome is disseminating and using both the RAI-MDS 2.0 clinical and demographic data.4. Use of Staff Skills/CompetenciesStaff skills and competencies requirements related to the RAI-MDS 2.0 have been identified and applied forstaff’s development, training, performance appraisals, and hiring processes.5. Healthy RAI-MDS 2.0 Working EnvironmentHome has mechanisms in place to support and promote a healthy RAI-MDS 2.0 practice environment, therebycontributing to staff’s physical, social, mental and emotional well-being.6. Data CompletenessHome adheres to RAI-MDS 2.0 completion timeline requirements and has a process in place to monitor dataaccuracy and completeness.For Information: 416.327.7625 4ltchrai@ontario.ca4

RAI-MDS 2.0 Quality Improvement Tool for Nutrition CarePart A: Use of Clinical Information TechnologyCriteria to Review Yes No Partial1. The nutrition care team has access to computer workstation or laptop with the RAI-MDS 2.0computer software.2. The nutrition care team has electronic access to the following: (check all that apply): E-mailing Internet RAI-MDS 2.0 scheduler (read only) RAPs triggers (read only) Outcome reports (read only)3. Nutrition care team members are able to print: RAI-MDS 2.0 assessment RAPs assessment summary Care plans4. Nutrition care team enters the following RAI-MDS 2.0 data directly into the computer software system(check all that apply): RAI-MDS 2.0 coding RAP assessment summary Care plansComments:Part B: Coordination of CareCriteria to Review Yes No Partial1. The nutrition care team contributes to (check all that apply): RAI-MDS 2.0 coding RAP review and RAP assessment summary documentation Care plan development and evaluation2. There is a clear process to communicate: RAI-MDS 2.0 assessment, RAPs and care planning timelines Significant Change in Status Full Assessments Data source to support accurate RAI-MDS 2.0mcoding (e.g. flow sheet) Revisions to the RAI-MDS 2.0 scheduler New admission, transfer or discharge Missing RAI-MDS 2.0 information Coding discrepancy or inaccuracy RAPs review and care planning schedule Non-triggered nutrition care clinical problems Dietitian referral3. In the absence of the dietitian and/or nutrition manager, there is a backup plan in place foraddressing nutritional: RAI-MDS 2.0 assessment RAP review and RAP and non-triggered clinical problem assessment summaries Care plan development and evaluation4. There are policies in the food service department outlining: RAI-MDS 2.0 coding RAP review and RAP assessment summary Care planning Dietitian referralFor Information: 416.327.7625 5ltchrai@ontario.ca5

Comments:Part C: Use of Data for Decision MakingCriteria to Review Yes No Partial1. The dietitian reviews targeted RAI-MDS 2.0 output reports regularly for the purpose of (check all thatapply): Monitoring resident care improvement Benchmarking best practices RAPs assessment summary development Care plan intervention evaluationExamples of quality indicator reports: Prevalence of weight loss; Prevalence of dehydrationIndicate RAI-MDS 2.0 output report(s): _________________2. There is evidence that the RAI-MDS 2.0 output information is incorporated in the nutritional RAPassessment summary as part of the critical analysis of data.3. Nutrition RAP triggered for RD referral or non-triggered nutrition RAP identified for RD referral areused in care conference and care plan development.4. RAI-MDS 2.0 output data is used to support continuous quality improvement initiatives for the Foodservice department.Indicate the RAI-MDS 2.0 output report(s): _________________________Comments:Part D. Use of Staff Skills/CompetenciesCriteria to Review Yes No Partial1. The nutrition care team received the following RAI-MDS 2.0 education or refresher includingsoftware training (check all that apply): RAI-MDS 2.0 coding RAPs and care planning RAI-MDS 2.0 outputs and reportsIndicate the date(s) of training: _______________________2. There is evidence of clearly written role functions for the nutrition care team members (dietitian andnutrition manager) involvement in: RAI-MDS 2.0 assessment RAP documentation Care planning3. The following resources are accessible and available for the nutrition care team (check all thatapply): RAI-MDS 2.0 nutrition care resource guide CIHI User’s Manual Frequently asked coding questions and answers4. There is a RAI-MDS 2.0 orientation program for the nutrition care team.5. RAI-MDS 2.0 competencies are built into the dietitian and nutrition manager performance appraisal.Comments:For Information: 416.327.7625 6ltchrai@ontario.ca6

E. Healthy RAI-MDS 2.0 Working EnvironmentCriteria to Review Yes No Partial1. The dietitian and/or nutrition manager have participated in the RAI-MDS 2.0 planning for changesthat affect the food service department.2. The dietitian and nutrition manager are able to provide feedback on RAI-MDS 2.0 to the RAICoordinator and/or management team and issues are addressed timely as required.3. The nutrition care team is kept informed on the RAI-MDS 2.0 implementation and the team knowswhere and how to access the information about RAI-MDS 2.0.4. There is a plan in place to address current nutritional care areas for improvement or concernsidentified by the dietitian and or nutrition manager.Please provide example:Comments:F. Data Completeness: Timelines and IntegrityCriteria to Review Yes No Partial1. RAI-MDS 2.0 assessment completion corresponds to the assessment scheduler. A plan is in place toaddress this issue if applicable.2. RAPs and non-triggered clinical problems review and documentation are complete according to theassessment scheduler. A plan is in place to address this issue if applicable.3. Care plan is developed according to the assessment scheduler. A plan is in place to address thisissue if applicable.4. There is evidence of annual data quality auditing for the following areas: nutrition RAI-MDS 2.0 items for coding accuracy RAPs and non-triggered clinical problems assessment summaries for documentationcompleteness care plan interventions for reflecting resident’s strengths, preferences and needs5. Results of the audits are communicated to the dietitian and nutrition manager and an action plan isdeveloped for improvement.Comments:Overall Comments:Reviewed completed by:Position:Reviewed Date:For Information: 416.327.7625 7ltchrai@ontario.ca7

Literature: Recommended Articles1. Bell J., Burger S., Kayer-Jones J. Malnutrition and Dehydration in Nursing Homes: Key Issues in Preventionand Treatment. National Citizens’ Coalition for Nursing Home Reform. June 2000.2. Blaum C.S., Fries B., Fiatarone M., Factors Associated with Low Body Mass Index and Weight Los inNursing Home Residents. Journal of Gerontology: Medical Sciences. 1995; Vol. 50A, No. J: M162-M168.3. Bowman J., Keller H. Assessing Nutritional Risk of Long-Term Care Residents. Canadian Journal of DieteticPractice and Research. Fall 2005; Vol 66 No 3: 155-161.4. Bowman J., Keller H. Using Minimum Data set to determine the prevalence of Nutritional Problems inOntario Population of Chronic Care Patients. Department of Family Relations and Applied Human Nutrition,University of Guelph, Guelph, ON5. Bowman J., Keller H. Validation of the oral/nutrition status section of the Minimum Data Set 2.0 for long-termcare residents. Department of Family Relations and Applied Human Nutrition, University of Guelph, Guelph,ONFor Information: 416.327.7625 8ltchrai@ontario.ca8