Article

In this article, the supervision, healthcare, and education experts at Robson Forensic provide an overview on the standard of care for providing food and fluid to individuals with dietary restrictions.

Food Safety for Individuals with Physical or Cognitive Impairments

A portion of all people in facility-based programs, such as childcare, nursing homes, educational and residential settings, group homes, and hospital settings suffer from conditions that make them vulnerable to choking and asphyxiation.

Within these settings, healthcare, rehabilitation, and education (HRE) professionals need to ensure that individuals under their care receive appropriate nutrition, hydration, and services to meet their needs. In facility based settings the HRE professionals rely on a specific process, sometimes referred to as the continuum of care, to assess clients and develop care plans that address the specific needs of each individual.

An important aspect of the assessment process for HRE professionals is to take into account the intrinsic and extrinsic factors that can affect an individual. This information can be obtained from a variety of sources including the individual’s records, staff, family and individual interviews, and direct and indirect observation. The assessment will help the HRE professionals define the individual functional limitations of a person and set the stage for the implementation of appropriate interventions.

Identify Potential Risks

Once a comprehensive assessment has been completed, HRE professionals will begin to identify potential food safety risks. This includes gathering intrinsic and extrinsic data about a specific individual regarding their health, functioning level, and the environment in which they act. Certain diseases and conditions that are identified as intrinsic factors can increase or decrease an individual’s ability to safely consume foods and fluids. For example, an individual with cognitive disabilities may not be able to eat independently. Intrinsically, he may not be able to determine the size or amount of food he can safely masticate or correctly manipulate utensils while eating. Additionally, the muscles in his mouth and throat may impair his ability to maneuver food in his mouth, to chew and to swallow. All of these factors put him at risk for malnutrition, choking, and aspiration and therefore may require interventions to assist in maintaining his safety during meals. Extrinsically, this same individual may become easily distracted during eating and drinking. Distractions such as a television or people occupying the same dining area may cause him to become unfocussed and “forget” to fully chew or swallow his food/fluids causing an increased risk for choking.

Evaluation & Analysis of Risks

After all potential risks have been identified; HRE professionals evaluate and analyze the risks and develop appropriate individualized interventions. During the evaluation and analysis of risk, HRE professionals carefully determine what interventions should be implemented to ensure safe food/fluid consumption for the individual.

Implement Interventions

The development of interventions for individuals in a variety of facility based settings is key for ensuring food/fluid safety. The purpose of the interventions is to limit the risk of an adverse event for the individual. The interdisciplinary team will review the assessments and risks identified and develop an individualized care/education plan. This plan will address identified causes, reflect the individual’s goals and choices, and identify specific interventions, time frames, and parameters for monitoring the interventions

An important aspect to the development and implementation of the individualized care/education plan includes communication between the comprehensive interdisciplinary team. This communication is particularly important for those who do not regularly interact with the individual. For example, if an individual with cognitive impairment and dysphasia (a swallowing impairment) requests a cup of water, all personnel regardless of whether they are existing, substitute, or temporary care givers would need to know the intervention methods needed to keep the individual safe. If the intervention in the care plan to “thicken all liquids to nectar thick consistency” is not known by an unfamiliar staff member, a drink of water could result in aspiration (fluid flowing into his lungs).

Monitor Interventions

Once interventions have been developed, implemented, and communicated the HRE professionals will monitor and evaluate them for effectiveness. The process of monitoring includes reviewing the intrinsic and extrinsic factors, assessment of the individual and the intervention methods, and observation of the individual. If during the process of monitoring, it is determined there has been a change in the individual or the interventions are not effective, the HRE professionals may implement new interventions. A consultation by a physician or speech therapist may be appropriate to best determine what interventions could be utilized.

Supervision

Throughout the settings, supervision plays an important part in food/fluid safety. Appropriate supervision by individuals who are knowledgeable about the care plan and how to apply the identified interventions, provides safety from the individual obtaining food/fluids that are dangerous due to temperature, consistency, or content due to dietary restrictions. Supervision ratios need to be addressed in the care/education plan so that when dining or drinking, the appropriate level of supervision is provided to ensure an individual is eating the correct food and beverage, in the correct manner, at the correct place, and in the correct setting. Whether the individual is an infant, child, adolescent, young adult, adult, or older adult, the process of supervision can decrease or eliminate negative outcomes.

Vulnerable Populations

Populations of individuals who experience food/fluid safety issues and are vulnerable to choking and asphyxiation (lack of oxygen to body from abnormal breathing) participate in many facility-based programs. These programs may include schools, childcare, adult day programs, nursing homes, skilled care, residential settings, group homes, and acute care and hospital settings.

The graph below provides a listing of some intrinsic and extrinsic factors that affect an individual who experiences food/fluid safety issues and interventions that may be implemented in care or education plans.

Supervision Investigations

Our supervision investigations evaluate the impact of supervision, or lack thereof, on the injury of an individual as it applies to a variety of settings. Effective supervision requires the training necessary to identify hazardous conditions and behaviors before they cause injuries, and the active involvement of intervention before things go wrong.

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Featured Expert

Stacy L. Donnelly, RN, BSN

Nursing Director & Healthcare Expert

Stacy Donnelly is a nursing director and healthcare expert with over 20 years of experience in patient care and regulatory compliance. Stacy’s experience as Director of Nursing for Philadelphia, Bucks, and Montgomery County retirement and rehabilitation communities focused on, among other areas, Federal, State, and Local Regulations. Her 12 years of experience as a Director of Nursing has contributed to her extensive experience in developing policies and procedures, investigating incidents and unusual occurrences, auditing patient care, monitoring adherence to policies and procedures, providing education to clinical staff, and ensuring compliance with local, state and federal regulations.

Stacy applies her expertise to forensic casework involving adverse events and wound care; claims of physical, emotional, financial, and mental abuse; patient care evaluations involving rehabilitation for substance abuse, pulmonology, orthopedics, cardiac, trauma, stroke, traumatic brain injuries, amputations, and spinal cord injuries; and nursing and facility operations/practices, standards of care, and hiring practices.