Quality assessment in nursing homes by systematic direct observation: feeding assistance

Background. Direct observation of care is an important data source for nursing home (NH) quality assessment, especially in light of evidence that chart information is inaccurate or incomplete for many daily care areas. The purpose of this study was to describe a standardized feeding assistance observational protocol that is designed for routine use by external (survey teams) and internal (licensed NH staff) quality assurance personnel to (i) maximize the amount of useful information gained from relatively brief observational periods; (ii) provide specific rules of measurement, which allow for replication and valid comparisons between NHs; and (iii) provide specific scoring rules that allow defensible categorical statements to be made about feeding assistance care quality within the NH. Methods. Four feeding assistance care quality indicators (QIs) were defined and operationalized in this study for 302 long-term residents in 10 skilled NHs: (i) Staff ability to accurately identify residents with clinically significant low oral food and fluid intake during mealtime; (ii) Staff ability to provide feeding assistance to at-risk residents during mealtime; (iii) Staff ability to provide feeding assistance to residents identified by the Minimum Data Set as requiring staff assistance to eat; and (iv) Staff ability to provide a verbal prompt to residents who receive physical assistance at mealtimes. Results. There were significant differences between facilities for three of the four QIs. The proportion of participants in each facility where staff "failed" the QIs ranged as follows: (Quality Indicator i) 42% to 91%; (ii) 25% to 73%; (iii) 11% to 82%; and (iv) 0% to 100%. Conclusions. A standardized observational protocol can be used to accurately measure the quality of feeding assistance care in NHs. This protocol is replicable and shows significant differences between facilities with respect to accuracy of oral intake documentation and the adequacy and quality of feeding assistance during mealtimes.