Search

Objectives: To determine the prevalence, rate of underdiagnosis and undertreatment, and association with activities of daily living dependency of spasticity in a nursing home setting., Design: Cross-sectional study., Setting and Participants: This study is an analysis of a deidentified data set generated by a prior quality improvement project at a 240-bed nursing home for residents receiving long-term care or skilled nursing care services., Methods: Each resident was examined by a movement disorders specialist neurologist to determine whether spasticity was present and, if so, the total number of spastic postures present in upper and lower limbs was recorded. Medical records, including the Minimum Data Set, were reviewed for neurologic diagnoses associated with spasticity, activities of daily living (ADL) dependency, and prior documentation of diagnosis and past or current treatments. Ordinary least squares linear regression models were used to evaluate the association between spasticity and ADL dependency., Results: Two hundred nine residents (154 women, 81.9 ± 10.9 years) were included in this analysis. Spasticity was present in 22% (45/209) of residents examined by the neurologist. Only 11% of residents (5/45) had a prior diagnosis of spasticity and were receiving treatment. Presence of spasticity was associated with greater ADL dependency (χ 2  = 51.72, P < .001), which was driven by lower limb spasticity (χ 2  = 14.56, P = .006)., Conclusions and Implications: These results suggest that spasticity (1) is common in nursing homes (1 of 5 residents), (2) is often not diagnosed or adequately treated, and (3) is associated with worse ADL dependency. Further research is needed to enhance the rates of diagnosis and treatment of spasticity in long-term care facilities., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: We sought to determine how delirium subtyped by arousal affected 6-month function and cognition in acutely ill older patients., Methods: This was secondary analysis of a prospective cohort study which enrolled hospitalized patients ≥65 years old. Delirium and arousal were ascertained daily in the emergency department and the first 7 days of hospitalization using the modified Brief Confusion Assessment Method and Richmond Agitation Sedation Scale, respectively. For each day, patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Preillness and 6-month functional status were determined using the Older American Resources and Services activities of daily living scale which ranges from 0 (completely dependent) to 28 (completely independent). Preillness and 6-month cognition were determined using the Informant Questionnaire on Cognitive Decline in the Elderly which ranges from 1 (markedly improved cognition) to 5 (severe cognitive impairment). Multiple linear regression was performed adjusted for preillness Older American Resources and Services activities of daily living and Informant Questionnaire on Cognitive Decline in the Elderly and other relevant confounders., Results: In 228 older patients, delirium with normal arousal was the only subtype independently associated with poorer 6-month function and cognition. For every day spent in this subtype, the 6-month Older American Resources and Services activities of daily living decreased by 0.84 points (95% confidence interval: -1.59 to -0.09) and the patient's 6-month Informant Questionnaire on Cognitive Decline in the Elderly significantly increased by 0.14 points (95% confidence interval: 0.06-0.23)., Conclusions: Delirium with normal arousal, as opposed to delirium with decreased or increased arousal, was the only arousal subtype significantly associated with worsening 6-month function and cognition. Subtyping delirium by arousal may have important prognostic value., (Copyright © 2018 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe a feasible quality improvement system to manage feeding assistance care processes in an assisted living facility (ALF) that provides dementia care and the use of these data to maintain the quality of daily care provision and prevent unintentional weight loss., Design and Methods: Supervisory ALF staff used a standardized observational protocol to assess feeding assistance care quality during and between meals for 12 consecutive months for 53 residents receiving dementia care. Direct care staff received feedback about the quality of assistance and consistency of between-meal snack delivery for residents with low meal intake and/or weight loss., Results: On average, 78.4% of the ALF residents consumed more than one-half of each served meal and/or received staff assistance during meals to promote consumption over the 12 months. An average of 79.7% of the residents were offered snacks between meals twice per day. The prevalence of unintentional weight loss averaged 1.3% across 12 months., Implications: A quality improvement system resulted in sustained levels of mealtime feeding assistance and between-meal snack delivery and a low prevalence of weight loss among ALF residents receiving dementia care. Given that many ALF residents receiving dementia care are likely to be at risk for low oral intake and unintentional weight loss, ALFs should implement a quality improvement system similar to that described in this project, despite the absence of regulations to do so., (Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine how delirium subtyped by level of arousal at initial presentation affects 6-month mortality., Design: This was a preplanned secondary analysis of two prospective cohort studies., Setting: Academic tertiary care emergency department (ED)., Participants: 1,084 ED patients who were 65 years old or older., Measurements: At the time of enrollment, trained research personnel performed the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation Sedation Score to determine delirium and level of arousal, respectively. Patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Death was ascertained by medical record review and the Social Security Death Index. Cox proportional hazard regression was used to analyze the association between delirium arousal subtypes and 6-month mortality., Results: Delirium with normal arousal was the only subtype that was significantly associated with increased 6-month mortality (hazard ratio [HR]: 3.1, 95% confidence interval [CI]: 1.3-7.4) compared with the no delirium group after adjusting for confounders. The HRs for delirium with decreased and increased arousal were 1.4 (95% CI: 0.9-2.1) and 1.3 (95% CI: 0.3-5.4), respectively., Conclusions: Delirious ED patients with normal arousal at initial presentation had a threefold increased hazard of death within 6 months compared with patients without delirium. There was a trend towards increased hazard of death in delirious ED patients with decreased arousal, but this relationship did not reach statistical significance. These data suggest that subtyping delirium by arousal may have prognostic value but requires confirmation with a larger study., (Copyright © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Nursing aides provide most of the labor-intensive activities of daily living (ADL) care to nursing home (NH) residents. Currently, most NHs do not determine nurse aide staffing requirements based on the time to provide ADL care for their unique resident population. The lack of an objective method to determine nurse aide staffing requirements suggests that many NHs could be understaffed in their capacity to provide consistent ADL care to all residents in need. Discrete event simulation (DES) mathematically models key work parameters (eg, time to provide an episode of care and available staff) to predict the ability of the work setting to provide care over time and offers an objective method to determine nurse aide staffing needs in NHs., Objectives: This study had 2 primary objectives: (1) to describe the relationship between ADL workload and the level of nurse aide staffing reported by NHs; and, (2) to use a DES model to determine the relationship between ADL workload and nurse aide staffing necessary for consistent, timely ADL care., Design: Minimum Data Set data related to the level of dependency on staff for ADL care for residents in over 13,500 NHs nationwide were converted into 7 workload categories that captured 98% of all residents. In addition, data related to the time to provide care for the ADLs within each workload category was used to calculate a workload score for each facility. The correlation between workload and reported nurse aide staffing levels was calculated to determine the association between staffing reported by NHs and workload. Simulations to project staffing requirements necessary to provide ADL care were then conducted for 65 different workload scenarios, which included 13 different nurse aide staffing levels (ranging from 1.6 to 4.0 total hours per resident day) and 5 different workload percentiles (ranging from the 5th to the 95th percentile). The purpose of the simulation model was to determine the staffing necessary to provide care within each workload percentile based on resident ADL care needs and compare the simulated staffing projections to the NH reported staffing levels., Measures: The percentage of scheduled care time that was omitted was estimated by the simulation model for each of the 65 workload scenarios using optimistic assumptions about staff productivity and efficiency., Results: There was a low correlation between ADL workload and reported nurse aide staffing (Pearson = .11; P < .01), which suggests that most of the 13,500 NHs were not using ADL acuity to determine nurse aide staffing levels. Based on the DES model, the nurse aide staffing required for ADL care that would result in a rate of care omissions below 10% ranged from 2.8 hours/resident/day for NHs with a low workload (5th percentile) to 3.6 hours/resident/day for NHs with a high workload (95th percentile). In contrast, NHs reported staffing levels that ranged from an average of 2.3 to 2.5 hours/resident/day across all 5 workload percentiles. Higher workload NHs had the largest discrepancies between reported and predicted nurse aide staffing levels., Conclusions: The average nurse aide staffing levels reported by NHs falls below the level of staffing predicted as necessary to provide consistent ADL care to all residents in need. DES methodology can be used to determine nurse aide staffing requirements to provide ADL care and simulate management interventions to improve care efficiency and quality., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Currently, the Agency for Healthcare Research and Quality (AHRQ) Common Format for nursing homes (NHs) accommodates voluntary reporting for 4 adverse events: falls with injury, pressure ulcers, medication errors, and infections. In 2015, AHRQ funded a technical brief to describe the state of the science related to safety in the NH setting to inform a research agenda. Thirty-six recent systematic reviews evaluated NH safety-related interventions to address these 4 adverse events and reported mostly mixed evidence about effective approaches to ameliorate them. Furthermore, these 4 events are likely inadequate to capture safety issues that are unique to the NH setting and encompass other domains related to residents' quality of care and quality of life. Future research needs include expanding our definition of safety in the NH setting, which differs considerably from that of hospitals, to include contributing factors to adverse events as well as more resident-centered care measures. Second, future research should reflect more rigorous implementation science to include objective measures of care processes related to adverse events, intervention fidelity, and staffing resources for intervention implementation to inform broader uptake of efficacious interventions. Weaknesses in implementation contribute to the current inconclusive and mixed evidence base as well as remaining questions about what outcomes are even achievable in the NH setting, given the complexity of most resident populations. Also related to implementation, future research should determine the effects of specific staffing models on care processes related to safety outcomes. Last, future efforts should explore the potential for safety issues in other care settings for older adults, most notably dementia care within assisted living., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

Objective: The purpose of this study was to evaluate an intervention to improve staff offers of choice to nursing home residents during morning care., Design: A controlled trial with a delayed intervention design., Setting: Four community, for-profit nursing homes., Participants: A total of 169 long-stay nursing home residents who required staff assistance with morning care and were able to express their care preferences., Intervention: Research staff held weekly training sessions with nurse aides (NAs) for 12 consecutive weeks focused on how to offer choice during four targeted morning care areas: when to get out of bed, when to get dressed/what to wear, incontinence care (changing and/or toileting), and where to dine. Training sessions consisted of brief video vignettes illustrating staff-resident interactions followed by weekly feedback about how often choice was being provided based on standardized observations of care conducted weekly by research staff., Measurements: Research staff conducted standardized observations during a minimum of 4 consecutive morning hours per participant per week for 12 weeks of baseline and 12 weeks of intervention., Results: There was a significant increase in the frequency that choice was offered for 3 of the 4 targeted morning care areas from baseline to intervention: (1) out of bed, 21% to 33% (P < .001); dressing, 20% to 32% (P < .001); incontinence care, 18% to 23%, (P < .014). Dining location (8% to 13%) was not significant. There was also a significant increase in the amount of NA staff time to provide care from baseline to intervention (8.01 ± 9.0 to 9.68 ± 9.9 minutes per person, P < .001)., Conclusion: A staff training intervention improved the frequency with which NAs offered choice during morning care but also required more time. Despite significant improvements, choice was still offered one-third or less of the time during morning care., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Guidelines written for government surveyors who assess nursing home (NH) compliance with federal standards contain instructions to observe the quality of mealtime assistance. However, these instructions are vague and no protocol is provided for surveyors to record observational data. This study compared government survey staff observations of mealtime assistance quality to observations by research staff using a standardized protocol that met basic standards for accurate behavioral measurement. Survey staff used either the observation instructions in the standard survey process or those written for the revised Quality Improvement Survey (QIS)., Methods: Trained research staff observed mealtime care in 20 NHs in 5 states during the same time period that survey staff evaluated care in the same facilities, although it could not be determined if survey and research staff observed the same residents during the same meals. Ten NHs were evaluated by government surveyors using the QIS survey instructions and 10 NHs were evaluated by surveyors using the standard survey instructions., Results: Research staff observations using a standardized observation protocol identified a higher proportion of residents receiving inadequate feeding assistance during meals relative to survey staff using either the standard or QIS survey instructions. For example, more than 50% of the residents who ate less than half of their meals based on research staff observation were not offered an alternative to the served meal, and the lack of alternatives, or meal substitutions, was common in all 20 NHs. In comparison, the QIS survey teams documented only 2 instances when meal substitutes were not offered in 10 NHs and the standard survey teams documented no instances in 10 NHs., Conclusions: Standardized mealtime observations by research staff revealed feeding assistance care quality issues in all 20 study NHs. Surveyors following the instructions in either the standard or revised QIS surveys did not detect most of these care quality issues. Survey staff instructions for observation of nutritional care are not clearly written; thus, these instructions do not permit accurate behavioral measurement. These instructions should be revised in consideration of basic principles that guide accurate behavioral measurement and shared with NH providers to enable them to effectively implement quality improvement programs.

Objectives: Recent research demonstrates that care recorded by nursing home (NH) staff is often inaccurate. Direct observations of care may therefore be of critical importance in assessing and improving care in this setting. Unfortunately, despite their apparent use in several types of quality assurance activities, there is little written information about the reliability or accuracy of observational procedures in NHs. This paper provides information about one important measurement issue (reactivity) that is often cited as a limitation of observational procedures in measuring usual care practices accurately., Design: Descriptive., Setting: Seven nursing homes., Participants: Staff and residents., Measurements: Direct observational time in bed; repositioning and feeding assistance., Results: Observational measures of care quality were stable over multiple observation periods and consistently detected quality problems even on the first and last days of observation., Conclusion: Direct observations of care provided to residents do not appear to change provider behavior.

Objective: All long-term care facilities are supposed to engage in quality improvement activities in an effort to improve care quality. The purpose of this pilot study was to teach long-term care staff how to conduct continuous quality improvement (CQI) related to nutritional care., Methods: Research staff conducted CQI training in one 48-bed pilot site with designated staff members. Supervisory staff were taught a standardized direct observational protocol, which was implemented weekly by both facility and research staff, to monitor defined nutritional care processes under the control of direct care staff. In addition, direct care staff received feedback on a weekly basis about care process implementation., Results: Following initial training and 12 weeks of CQI implementation, there were improvements in all 5 nutritional care processes related to the adequacy and quality of daily feeding assistance care provision according to both facility and research staff data. Weekly CQI implementation required approximately 1 hour of supervisory staff time and less than 15 minutes of direct care staff time to receive feedback., Implications: Both initial training and weekly CQI implementation were effective and required less than 2 hours of total staff time per week. Long-term care staff in this pilot site were able to improve nutritional care quality using a standardized direct observational protocol to guide CQI activities.

Context: Assessment and management of pain for nursing home residents is frequently reported to be inadequate, yet few studies have used objective criteria to measure the quality of care related to pain., Objective: Field test a standardized resident interview and medical record review protocol to assess and score quality indicators relevant to pain., Design: Descriptive., Setting: Thirty nursing homes (NHs)., Participants: Seven hundred ninety-four residents met overall eligibility criteria. Quality indicators were scored for those residents who met specific eligibility requirements for each pain indicator., Measurements: Medical record reviews were completed for 542 participants, and data were used to score 12 indicators related to pain assessment, management, and response to treatment. A seven-item pain interview was attempted with all 794 participants and completed with 478 participants who were rated by NH staff as cognitively aware., Results: Quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of participants (227/478) reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; but, more than 50% of those reporting symptoms of chronic pain on interview had nurse pain scores of 0 for 4 consecutive weeks prior to interview., Conclusions: Infrequent or incomplete physician pain assessment and treatment and inaccurate documentation by licensed nurses limits evaluation of pain care quality based on medical record review alone. A brief resident interview identified participants reporting symptoms of chronic pain not documented in the medical record and those with a preference for medication. Initial targeting of residents with self-reported pain maximizes the efficiency of the standardized scoring system described in this study. Focusing on explicit process measures clearly identifies areas for improvement and represents an important step in assessing the quality of pain care in the NH.

Context: Assessment and management of pain for nursing home residents is frequently reported to be inadequate, yet few studies have used objective criteria to measure the quality of care related to pain., Objective: Field test a standardized resident interview and medical record review protocol to assess and score quality indicators relevant to pain., Design: Descriptive., Setting: Thirty nursing homes (NHs)., Participants: Seven hundred ninety-four residents met overall eligibility criteria. Quality indicators were scored for those residents who met specific eligibility requirements for each pain indicator., Measurements: Medical record reviews were completed for 542 participants, and data were used to score 12 indicators related to pain assessment, management, and response to treatment. A seven-item pain interview was attempted with all 794 participants and completed with 478 participants who were rated by NH staff as cognitively aware., Results: Quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of participants (227/478) reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; but, more than 50% of those reporting symptoms of chronic pain on interview had nurse pain scores of 0 for 4 consecutive weeks prior to interview., Conclusions: Infrequent or incomplete physician pain assessment and treatment and inaccurate documentation by licensed nurses limits evaluation of pain care quality based on medical record review alone. A brief resident interview identified participants reporting symptoms of chronic pain not documented in the medical record and those with a preference for medication. Initial targeting of residents with self-reported pain maximizes the efficiency of the standardized scoring system described in this study. Focusing on explicit process measures clearly identifies areas for improvement and represents an important step in assessing the quality of pain care in the NH.

Objective: The objective of this study was to examine the association between psychoactive medications and sleep quality in a sample of nursing home patients., Design: We studied a baseline data collection for a clinical trial of a nonpharmacologic sleep intervention program., Setting: This study was conducted at six community nursing homes., Participants: We studied 168 nursing home patients., Methods: Sleep was recorded by wrist actigraphy for three to five nights under usual care conditions. Demographic and clinical data were collected by medical record reviews and patient assessments., Result: One or more routine psychoactive medications were being taken by 109 (65%) of the patients. Number of minutes of sleep, percent of time in bed asleep, and number of awakenings did not differ between those receiving and not receiving a psychoactive medication. Neither the use of antidepressants nor the use of only psychoactive medications reported to cause sedation was associated with significantly better sleep quality., Conclusion: Psychoactive medications as a general class of drugs were not associated with better or worse sleep quality in this very frail nursing home population. The effect of individual classes of psychoactive drugs on sleep quality in this patient population requires further study.

Objectives: The objectives of this study were to describe changes in prescription analgesic and antidepressant medications and to track the costs associated with these medication changes when elderly Medicaid beneficiaries move from the community to a nursing home setting., Design: Retrospective analysis of Medicaid long-term care and drugs claims data for fiscal year 2000 from three different states., Setting: Long-term care facilities in three different states., Participants: We studied 1321 elderly Medicaid beneficiaries newly admitted to a nursing home during the study period., Measurements: Pain medications were grouped into four different categories and all antidepressants were grouped into one category. For each medication category, we obtained the number of unique patients for whom it was prescribed, the number of days it was prescribed, and the amount paid by Medicaid. We then calculated the percentage of subjects prescribed and the amount paid per day for each medication class before and after nursing home admission., Results: Except for skeletal muscle relaxants, 21% to 39% of beneficiaries already had claims linked to each medication class while still living in the community. After nursing home admission, the percentage of beneficiaries exposed to each medication class increased by 2% to 33%. Cost per day of therapy increased by 10% to 83%. There was significant variation among the states in utilization and cost per day of therapy., Conclusions: We draw three major conclusions: (1) community-dwelling elderly Medicaid beneficiaries in this study use more prescription analgesics and antidepressants than community-dwelling elders in prior studies; (2) there is a significant increase in medication utilization and cost on nursing home admission; and (3) significant variability in medication use and cost exists among the three states examined. Further investigation to elucidate the reasons for these differences could assist legislators in formulating sound public policy to contain Medicaid expenditures without sacrificing patient care.

Objectives: To determine the incidence of acute medical conditions in incontinent nursing home residents, and associated costs of diagnostic testing and treatment, Design: Prospective, cohort study., Setting: Three community nursing homes., Participants: 161 long-stay residents with urinary incontinence in (mean age 86 years, 77% female, 92% white)., Measurements: Acute medical conditions were identified prospectively through medical record review based on standardized criteria. All diagnostic testing and treatment provided for these conditions were recorded, and related costs in the nursing home were assigned based on 1997-1998 Medicare and Medicaid reimbursement., Results: The highest incidences of illness were for dermatological conditions (107 episodes per 1000 patient-weeks, involving 70% of subjects), respiratory illnesses (29 per 1000 patient-weeks, 47% of subjects) and gas-trointestinal illnesses (24 per 1000 patient-weeks, 36% of subjects). Among episodes with an incidence of at least 5 per 1000 patient-weeks, the illness events with the highest median diagnostic testing and treatment costs per episode were pneumonia, acute bronchitis, and depression. Only 42 out of the total 1071 episodes identified resulted in a hospitalization. Significant predictors of higher illness incidence included greater baseline comorbidity and higher number of routine medications (model adjusted R-square = 0.319, P = 0.021)., Conclusion: Acute illness is very common among incontinent nursing home residents, and is generally diagnosed and treated at the nursing home site, with variation among conditions in associated costs. Important policy implications include resource allocation (including appropriate staffing patterns), educational and quality improvement activities, and future research and guideline development for the optimal management of medical conditions in the nursing home setting.

Objectives: To determine the incidence of acute medical conditions in incontinent nursing home residents, and associated costs of diagnostic testing and treatment, Design: Prospective, cohort study., Setting: Three community nursing homes., Participants: 161 long-stay residents with urinary incontinence in (mean age 86 years, 77% female, 92% white)., Measurements: Acute medical conditions were identified prospectively through medical record review based on standardized criteria. All diagnostic testing and treatment provided for these conditions were recorded, and related costs in the nursing home were assigned based on 1997-1998 Medicare and Medicaid reimbursement., Results: The highest incidences of illness were for dermatological conditions (107 episodes per 1000 patient-weeks, involving 70% of subjects), respiratory illnesses (29 per 1000 patient-weeks, 47% of subjects) and gastrointestinal illnesses (24 per 1000 patient-weeks, 36% of subjects). Among episodes with an incidence of at least 5 per 1000 patient-weeks, the illness events with the highest median diagnostic testing and treatment costs per episode were pneumonia, acute bronchitis, and depression. Only 42 out of the total 1071 episodes identified resulted in a hospitalization. Significant predictors of higher illness incidence included greater baseline comorbidity and higher number of routine medications (model adjusted R-square = 0.319, P = 0.021)., Conclusion: Acute illness is very common among incontinent nursing home residents, and is generally diagnosed and treated at the nursing home site, with variation among conditions in associated costs. Important policy implications include resource allocation (including appropriate staffing patterns), educational and quality improvement activities, and future research and guideline development for the optimal management of medical conditions in the nursing home setting.

Objective: to evaluate the accuracy of nursing home (NH) staff in documenting two Minimum Data Set (MDS) items that are used to identify residents at risk for undernutrition, low oral intake and food complaints, using standardized observation and interview assessment protocols implemented by research staff., Design and Methods: MDS information related to low oral intake (item K4c: <75% of most meals) and complaints about the taste of food (item K4a) was compared to independent evaluations of low oral intake and food complaints for a random sample of 75 residents in two proprietary NHs within the same month that a complete MDS assessment was due for each participant. Direct observations were conducted by research staff during nine mealtime periods for 3 consecutive days according to a standardized mealtime observational protocol to estimate low oral intake; and, two one-on-one interviews with residents were conducted on two consecutive days using standardized questions to assess the stability of food complaints., Results: Research staff documentation based on direct observation and resident interviews showed a significantly larger number of residents being identified as potentially at risk for undernutrition due to low oral intake (73%) and/or stable complaints about the taste of food (32%) as compared with NH staff documentation of MDS items K4c (44%) and K4a (0%), respectively, within the same month. A total of 47% of the participants expressed stable complaints about some aspect of the NH food service (eg, variety, appearance, temperature)., Conclusion: The documentation of low oral intake and food complaints on the MDS was inaccurate and resulted in a significant underestimate of residents with either of these risk factors for undernutrition.