Food and Nutrition in Long-Term-Care Homes – Part 6

Part 6: Why you need a menu management system

This is what was recommended from the Auditors: 

Recommendation 1

To provide residents with safe and appropriate food and nutrition services that are in accordance with their plans of care and reduce the risk of food-related harm to residents, we recommend that long-term-care homes develop ways to ensure that all direct-care staff have timely access to the most current plans of care of the residents for food and nutrition before serving food.

Recommendation 2

To remind long-term-care homes of the importance of providing residents with safe and appropriate food and nutrition services that are in accordance with their plans of care and reduce the risk of food-related harm to residents, we recommend that the Ministry of Long-Term Care confirm during its inspection process that all direct-care staff are able to know the residents’ plans of care for food and nutrition before serving food.

While the regulation requires homes to have a system to monitor food and fluid intake of residents, Ministry inspectors only look at food and fluid consumption records if the inspection was related to a resident at a nutrition or hydration risk. Ministry inspectors would only review completeness and accuracy of records related to the inspection they are doing and not for all residents. Reviewing the home’s system for monitoring resident food and fluid intake as a whole could help proactively minimize the nutrition and hydration risk posed to other residents.  A food and nutrition menu system like mitrition is exactly what homes need. 

Recommendation 3

To better meet the dietary needs of their residents, as assessed in their plans of care and proactively mitigate nutritional risks to residents, we recommend that long-term-care homes:

• communicate to their staff the importance of complying with internal policies to refer residents for registered dietitian assessment and maintain complete and accurate food and fluid consumption records; and
• allocate more time for the registered dietitians to proactively monitor the nutrition and hydration risk posed to all residents such as observing residents eating at mealtimes, attending resident-care conferences and providing education to residents, staff and family members.

Recommendation 4

To confirm that long-term-care homes are meeting the residents’ dietary needs as assessed in their plans of care and proactively mitigate nutritional risks to residents, we recommend that the Ministry of Long-Term Care:

• monitor whether long-term-care homes’ staff are complying with internal policies to refer residents for registered dietitian assessment and maintain complete and accurate resident food and fluid consumption records;
• establish protocols for registered dietitians to allocate more time for observing residents eating at mealtimes, attending resident-care conferences and providing education to residents, staff and family members; and
• during their inspections, review long-term care homes system for monitoring resident food and fluid consumption as a whole to see how they proactively minimize the nutrition and hydration risk posed to other residents.

Our review of menus and recipes from a sample of long-term-care homes showed that residents were not provided with food that had adequate nutrients, fibre and energy based on the current Dietary Reference Intakes values. With the assistance of an independent registered dietitian, we found that food on the homes’ menus contained sufficient protein and energy as measured in calories, but excessive or insufficient nutrients as compared to recommendations made in the Dietary Reference Intakes such as:

• too much sugar (40% to 93% above recommended amount), mainly in juice, fruit drinks and bakery items, which increases the risk of obesity and type 2 diabetes
• too much sodium (32% to 59% above recommended amount), mainly in entrees and soups, which increases the risk of high blood pressure, stroke and heart failure;
• too much saturated fat (19% to 69% above recommended amount), mainly in entrees, which increases the risk of heart disease;
• not enough fibre (19% to 34% below recommended amount), which increases the risk of constipation;
• not enough potassium (14% to 42% below recommended amount), usually found in fresh fruit and vegetables that help lower blood pressure; and
• not enough magnesium (5% to 35% below recommended amount), usually found in fresh beans, nuts, seeds, fish and whole grains that promote healthy bones, muscles and nerves.

Serving food that contains insufficient nutrients may contribute to poor health outcomes. At the time of our audit, in the five homes where we conducted detailed work, registered dietitians assessed that 39% of residents were at a “high nutritional risk.” Statistics Canada defines people with high nutritional risk as those who need further assessment and intervention to prevent or reverse the consequences of chronic under-nutrition. Regulation requires that the home’s registered dietitian approve the menu, which should be in accordance with Canada’s Food Guide and the Dietary Reference Intakes. Of the five homes where we conducted detailed work, two could not provide evidence that their registered dietitian analyzes the home’s menu, two performed minimal analysis and instead relied on the corporate dietitian to perform the analysis, and one performed analysis as required. Even though some registered dietitians have noted exceptions such as high sodium, they still approved the menus with certain nutrients being over or below the recommended values. For example, the registered dietitian at one home who had concerns with the menu’s sodium content did not change the current menu cycle but, instead, made recommendations to decrease the sodium in the next menu cycle. We could not verify whether the next menu had sodium adjusted because the menu was not finalized when we completed the audit. As well, two of the five homes did not even have data on the sugar content in their menus and were therefore unable to demonstrate they meet Dietary Reference Intakes recommendations for sugar. While Ministry inspectors have protocols to review nutrition levels of menus, the Ministry informed us that it would be unlikely an inspection would require a review of the entire menu cycle. An inspector would likely only review nutrition levels of a particular day if there were complaints about the nutrients provided or if the inspector observed unusual meals in the dining room. At the five homes where we conducted detailed work, registered dietitians and nutrition managers informed us that in the last three years Ministry inspectors never asked them for the nutrient analysis of the home’s menu.

Having a menu management system like mitrition will allow you to have nutritionals and totals at your finger tips.  All recipes have nutritionals attached to them even if you make changes and swap them in and out of menus. 

Recommendation 5

To increase the likelihood that residents receive food and fluids with adequate nutrients, fibre and energy, we recommend that long-term-care homes’:

• registered dietitians make appropriate menu changes to achieve compliance with the current Canada’s Food Guide and Dietary Reference Intakes requirements; and
• management monitor their menus for compliance with the current Canada’s Food Guide and Dietary Reference Intakes requirements.

A menu management system will help with menu changes and the proper calculation of total nutritionals to meet the requirements. 

Recommendation 6

To increase positive health outcomes and assist residents in receiving food and fluid with adequate nutrients, fibre and energy, we recommend that the Ministry of Long-Term Care:

• support long-term-care homes to develop and implement a transition plan setting out when long-term-care homes need to fully adopt the 2019 Canada’s Food Guide; and
• instruct its inspectors to regularly verify that long-term-care-home menus are meeting the current Canada’s Food Guide and Dietary Reference Intakes requirements as part of their inspection protocol and review the long-term-care home’s nutrient analysis of its menus.

Recommendation 7

To minimize the risk of residents consuming low-quality food, we recommend that long term-care homes require and monitor that their staff abide by the internal food storage policy, including not storing food beyond their best before date.

Recommendation 8

To minimize the risk of residents consuming low-quality food, we recommend that the Ministry of Long-Term Care require its inspectors to regularly verify that food items in refrigeration and storage in long-term-care homes are not beyond their best-before date.

Recommendation 9

To promote quality of life and provide timely assistance during mealtimes to residents, we recommend that long-term-care homes evaluate alternative staffing options to provide assistance to residents during peak demand times such as mealtimes; for example, volunteer or students trained in feeding residents with dementia.

Recommendation 10

To promote quality of life and provide timely assistance during mealtimes to residents, we recommend that the Ministry of Long-Term Care:

• clarify to long-term-care homes that alternative staffing options exist that can be used to provide assistance to residents during peak demand times such as mealtimes; for example, part-time staff, volunteers or students trained in feeding residents with dementia; and
• develop and implement an updated staffing strategy for the long-term-care home sector that considers the varying needs of residents throughout the day.

Recommendation 11

To allow more long-term-care home residents to eat in a safe and home-like environment, we recommend that the Ministry of Long-Term Care:

• re-evaluate whether its home design requirements for homes constructed before 2009 continue to be reasonable given the increased use of mobility devices in long term-care homes today; and
• determine what measures to put in place for homes that do not have dining spaces under the current design manual to increase the comfort of their residents during mealtimes.

Recommendation 12

To minimize the risk of gastroenteritis outbreaks in long-term-care homes, we recommend that long-term-care homes regularly assess compliance with the Ministry of Health’s policy on hand hygiene around mealtimes and correct on a timely basis any weaknesses that they identify through these reviews.

Recommendation 13

To minimize the risk of gastroenteritis outbreaks in long-term-care homes, we recommend that the Ministry of Long-Term Care monitor to ensure that long-term-care homes regularly assess compliance with the Ministry of Health’s policy on hand hygiene around mealtimes, and correct on a timely basis any weaknesses that they identify through these reviews.

Recommendation 14

To limit the impact of food waste on the environment, we recommend that the Ministry of Long Term Care:

• work with the Ministry of the Environment, Conservation and Parks to establish a goal of diverting food and organic waste generated in long-term-care homes; and
• work with the associations that represent the long-term-care home sector to develop guidelines to help long-term-care homes meet this goal.

Recommendation 15

To achieve further cost savings in purchasing food for the long-term-care-home sector, we recommend that Ministry of Long-Term Care, in conjunction with the Ministry of Health:

• identify the organization(s) responsible for co-ordinating group purchasing for long term-care homes;
• determine how best to group the long term-care homes, such as by region or by ownership type, in future food-buying arrangements, until the organization(s) responsible for co-ordinating group purchasing is identified; and
• assist in the establishment of group buying contracts where needed, until the organization(s) responsible for co-ordinating group purchasing is identified.

Recommendation 16

To demonstrate that residents receive the best possible nutritional care, we recommend that the Ministry of Long-Term Care, in conjunction with long-term-care homes:

• identify appropriate meaningful performance indicators that measure how effective a long-term-care home is at meeting residents’ food and nutrition needs;
• set performance targets and regularly assess actual results against these targets; and
• report publicly on the results.

Recommendation 17

To improve the well-being and safety of long term-care home residents, we recommend that long-term-care homes formally share best practices related to food and nutrition with each other.

Recommendation 18

To improve the well-being and safety of long term-care home residents, we recommend that the Ministry of Long-Term Care identify commonly occurring issues related to food and nutrition from data collected through critical incidents and inspections, and provide information and recommend best practices to long term-care homes.

Recommendation 19

To decrease long-term-care home residents’ harm or the risk of harm, we recommend that the Ministry of Long-Term Care respond to all critical incidents reported by long-term-care homes within prescribed timelines.

http://www.auditor.on.ca/en/content/annualreports/arreports/en19/v1_305en19.pdf