Part 1: Why you need a menu management system

The Office of Ontario’s Auditor General released an audit about food and nutrition in long term care homes.  There are more than 77,000 adults that live in Ontario’s 626 long-term-care homes. The Ministry of Long-Term Care funds the homes to provide residents with the 24-hour nursing care and help with daily living activities that they need in a protective, safe and supportive environment.

At the time of the audit, the average age of a resident in Ontario’s long-term-care homes was 83. Compared with a 2009 report, the current population of residents are more cognitively impaired and require more assistance with daily living than in the past. The percentage of residents with a form of dementia has increased from 56% in 2009 to 64% in 2019.

People with dementia require more help with the basic daily activities, including eating and drinking. It was stated that in 2016, there were 228,000 people living with dementia and this number is expected to grow to over 430,000 by 2038. Providing food and nutrition services to residents will be more challenging for long-term-care homes with the anticipated increase in the number of people with dementia.

A daily activity in long-term-care homes is eating, with the dining experience being one of the most social times of day.  Families of the residents count on long-term-care homes to care for their vulnerable loved ones.  On the other hand, the residents themselves depend on nutritious delicious food to maintain their well-being in a pleasurable environment. The audit showed that residents rarely had family or friends join them during mealtimes and relied on personal support workers (PSW’s) to help provide their appropriate food and nutrition choices.

The Ministry will go in to inspect long-term-care homes on different aspects related to food, such as dining room observation for pleasurable dining environments, menu planning, and evaluating nutritional and hydration risks to residents. Also, Ontario’s 35 public health units, which are co-funded by the Ministry of Health and municipalities, inspect the homes for food-safety concerns such as food temperature controls such as HACCP, kitchen sanitation, pest control and food-preparation practices.

The consequences of improper food and nutrition care are quite significant. Between January 2018 and May 2019, long-term-care homes had reported over 660 incidents involving food and nutrition issues. These included residents choking, missed meals, staff feeding residents food with the wrong texture, and gastroenteritis outbreaks. These outbreaks could be caused by contaminated food or drink, or spread through contact with the infected persons or contaminated items for reasons like poor handwashing practices as an example. This works out to about 1.3 incidents a day and includes 27 cases of unexpected deaths for reasons such as choking or aspiration and about 100 cases of abuse, neglect or improper treatment of a resident by home staff related to food that resulted in harm or risk of harm to the resident. Choking will occur when a foreign object becomes obstructed in a person’s airway and aspiration will occur when a person has accidentally inhaled an object or fluid into their windpipe or lungs.

The audit found that some of the long-term-care homes were not consistently providing residents with sufficient high-quality food and nutrition care. Further, the Ministry could do more through its inspection program to help confirm that long-term care homes are providing a safe and comfortable eating environment and good quality food to help residents enjoy a more home-like pleasurable dining experience at the long-term-care homes. In some cases, residents were subject to unnecessary risks that made them ill, simply just by eating and drinking.

Some of the more significant audit findings included:

  • Mealtime service is affected when personal support workers tend to other responsibilities or do not report to work.
  • Residents in older long-term-care homes can be less likely to enjoy meals in a homelike environment.
  • Long-term-care staff do not consistently follow the residents’ plan of care, increasing the risk that residents may be eating the wrong food. A menu management system would minimize this.
  • Long-term-care homes’ registered dietitians do not spend sufficient time proactively monitoring residents.
  • Menus do not have recommended nutrients for residents compared to the recommendations in the Dietary Reference Intakes. A menu management system would minimize this.
  • Long-term-care homes are offering residents food and drinks high in sugar; high sugar intake can contribute to heart disease, stroke, obesity, diabetes, high blood cholesterol, cancer and poor dental health. A menu management system would minimize this by calculating nutritionals. 
  • In three of the five long-term-care homes where we conducted detailed work, some food used to make meals was past its best before date.
  • Only 19% of residents observed to have washed their hands to proactively prevent and control infections.
  • Group purchasing has not been fully explored to help long-term-care homes realize higher savings to allocate to potentially higher-quality food.
  • The Ministry does not require long-term care homes to report on performance indicators related to food and nutrition.

So, what did all conclude?  Well the audit concluded that the Ministry of Long-Term Care and the long-term-care homes do not have sufficient procedures in place to confirm that residents are receiving sufficient mealtime assistance and that they receive food and nutrition services in accordance with their individual plans of care.

Menus that long-term-care home registered dietitians approved did not always meet nutritional requirements in accordance with Canada’s Food Guide and the Dietary Reference Intakes.  A menu management system would minimize this by calculating nutritionals.

Some residents who require help to eat and drink are having to wait longer when personal support workers tend to other responsibilities. Staffing is not consistently allocated optimally to provide residents with the resident-centred care that meets their dietary and nutritional needs at meal time including feeding assistance requirements.

What was the response from the Ontario Long Term Care Association

“We agree with the Office of the Auditor General that more supports are needed to improve the food and nutrition care of those living in long term-care homes. The issues outlined in the report are a symptom of a systemic shortfall of funding and other supports that have contributed to a severe staffing shortage.  As the report recognizes, people who live in long-term care have increasingly complex needs. In the last decade, there has been a significant increase in acuity and the number of people who need support with daily activities such as eating and drinking. Yet funding and other supports have not kept pace. Improving the dining experience for residents is also dependent on a massive infrastructure program to rebuild and modernize Ontario’s long-term care homes.

Another important consideration for the findings in this report is resident choice. Long term-care homes are rapidly adopting the people-centred approach to care that honours personal preferences and habits, rather than an institutional model. Many people in long-term care prefer to eat a diet they find familiar, even if it is “less nutritious.” Many are also near the end of life when the desire to eat and drink naturally diminishes. The rights of seniors living in long-term-care homes, including those with dementia, to decide what they wish to eat or drink must be respected. The Long-Term Care Homes Act, 2007 and its dietary requirements are based on the old institutional model of care.

We recommend government work with the sector to move forward on the development of a health human resources strategy to address the staffing crisis and nutrition issues in long-term care homes”.

What was the response from the Ministry? 

“The fundamental principle of the Long-Term Care Homes Act, 2007(Act) is to provide a place for residents to live with dignity and in security, safety and comfort. Dietary services, nutritional care and hydration programs are central to maintaining the well-being of over 78,000 long term-care home residents in Ontario.

The government understands that nutritious food is critical to overall care and as such, the Ministry of Long-Term Care appreciates the comprehensive audit conducted by the Auditor General on Food and Nutrition in Long Term-Care Homes.

The Act and Ontario Regulation 79/10 require that every licensee of a long-term-care home ensures that there are organized programs of nutrition care and dietary services to meet the daily nutrition needs of the residents. Each day, there are over 234,000 meals served in long-term-care homes, which is over 85 million meals per year. Reported food related incidents represent less than 1% of these daily interactions.

The Auditor General made a recommendation to the Ministry in the 2015 audit of Long-Term-Care Home Quality Inspection Program to put the safety of residents first by focusing on high-risk areas. As a result, in fall of 2018, the Ministry shifted to a risk-based compliance program to prioritize inspections and resources for situations that put the residents at highest risk.

The Ministry has made a combination of investment and policy changes over the past few years to ensure that residents’ nutritional requirements are met. Since 2011/12, the Raw Food per diem has increased by more than 28%.

In 2019/20, the Ministry provided a global per diem increase of 1% to the Level of Care funding. We are investing $72 million more into long-term care this year. This is in addition to $1.75 billion invested to create 15,000 new long-term care beds and redevelop 15,000 older long-term care beds over five years.

We actively engage with partners to support innovation in the delivery of long-term-care services and infrastructure, including ensuring that proposed long-term-care home development and infrastructure projects serve the needs of their communities”.

The audit also observed that nutrition care and dietary services in long-term-care homes are among the key programs that enhance residents’ quality of life. Each day, homes provide residents with three meals, as well as two snacks and three drinks between meals.

Many residents consider dining times to be one of the most social times of the day.  A long-term-care-home resident can also use food and nutrition to restore health or prevent its deterioration. As an example, an increase in calcium and vitamin D intake can reduce serious risks of bone fractures from falls. For some residents, appropriate quantity and quality of food intake can help control diseases related to the heart, blood pressure, strokes, dementia and blood-sugar levels. In the opposite, inadequate or improper nutrition and dietary intake increases the risk of health consequences such as malnutrition, dehydration, delayed healing of wounds, and foodborne illnesses.

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