Assignments

Chapter 11

Dietary Services

What You Will Learn

•  Food has universal appeal, but in nursing facilities it must also address a variety of nutritional issues.

•  The food service director oversees the entire dietary operation and is responsible for staffing, purchasing, inventory management, and cost control. Traditional facilities have cooks, helpers, and dietary aides to staff the kitchen. A registered dietitian functions as a consultant.

•  Menu planning requires consideration of meal plans, menu choice, and menu cycle.

•  Several factors should be considered when selecting menu items. Menus must be nutritionally balanced, include dishes that are palatable, and be within budgetary cost allowances. Standardized recipes and portions are designed to yield consistent quality and cost.

•  Selection of vendors should be based on reliability, quality, and cost. Ordering schedules vary by the type of food product. Even independent facilities can take advantage of combined buying power by joining a group purchasing organization.

•  Blind receiving is a more reliable method than invoice receiving for order delivery. Food storage temperatures must be monitored.

•  Ordering cycles and state regulations determine the number of days worth of food supplies that must be on hand. Adequate inventory control is based on perpetual and physical inventory systems. The physical inventory is also used for food costing.

•  Food production requires planning and contingency arrangements. Each of the main production methods has its advantages and disadvantages.

•  Modified diets can be simple or complex. Supplements are used when special nutritional issues exist. Between-meal snacks can be beneficial for some residents.

•  Food acceptability and intake issues should be addressed. Various types of interventions can improve food intake for dementia patients.

•  Various conditions may necessitate the use of enteral or parenteral feeding methods to maintain adequate nutritional intake.

•  Centralized food service is more traditional than decentralized service. Each has its advantages and disadvantages that must be evaluated before making a switch from one type of service to another. Maintaining foods at their right serving temperatures is a main challenge in food service.

•  Food poisoning is almost entirely preventable by practicing good sanitation and good food handling techniques.

Introduction

Food has universal appeal as a necessity for physical sustenance, as a means of sensory gratification, and as an agent for creating social interaction. These three major aspects of food provide the basic principles that guide food preparation and service in nursing facilities. For patients who have special dietary needs, food intake must also serve a therapeutic purpose.

In many nursing facilities, the dietary department is also responsible for preparing meals for the staff, visitors, and volunteers. In most cases, preparing food separately for residents, staff members, and guests is impractical. Hence, the basic menu should be designed to meet the needs of all these groups. Generally, the dietary department is also responsible for making refreshments or special preparations for certain activities such as parties and functions. Some large facilities may also have contracts to prepare meals for the local Meals On Wheels program. Some facilities contract food preparation to outside vendors. However, most facilities operate their own kitchens to serve the particular needs of their residents. In newer facilities in particular, smaller household-style kitchens and dining services are catching on as part of the culture change movement.

Dietary services must address the needs of those who have loss of appetite, difficulty feeding themselves, problems with chewing, swallowing difficulties, and inadequate nutrition. Other dietetic needs are related to diseases such as diabetes, heart conditions, or liver disease. Patients with dementia require appropriate interventions.

Dietary Department

Supervision

After nursing services, dietary is the second largest department in a nursing facility. The department is managed by a full-time food service director, also known as dietary manager, who reports to the administrator. State regulations specify the qualifications required for the position of dietary manager. The two most common choices for filling the dietary manager’s position are a registered dietetic technician (DTR) who holds an associate’s degree in general dietetics, or a Certified Dietary Manager (CDM) who has completed the requirements for certification by the Dietary Managers Association (DMA).

The dietary manager has both management and clinical responsibilities. This individual is responsible for staffing functions that include hiring, training, and scheduling; purchasing food and supplies; inventory management; and managing the food preparation and food service within the departmental budget. The dietary manager supervises all aspects of dietary operations such as food storage, food production and preparation of therapeutic diets, meal service, dishwashing, and sanitation. Clinical responsibilities of this position include nutritional screening, assessment, care planning, diet planning, and documenting progress notes in consultation from a clinical dietitian.

Large facilities require one or more assistant food service managers. Dietary managers and assistants should supervise the preparation and service of all meals and share clinical responsibilities. Supervision should also be provided on weekends and holidays, particularly when special meals are planned and when the facility is likely to have more than the usual number of visitors, some of whom may have a meal with the residents they may be visiting.

Food Service Assistants

The dietary department has three main categories of food service workers who perform a number of functions in the main kitchen under the general direction of the dietary manager, and assistant food service manager, if the facility has the latter position. They include cooks, cook’s helpers, and dietary aides. Cooks and their helpers are responsible for food preparation. Cooks prepare the main dishes (also known as entrées) and are responsible for portion control. Cook’s helpers may assist with the preparation of main dishes, but their main job is to prepare side dishes, such as potatoes, pasta, vegetables, and salads. Dietary aides are responsible for portioning out food at the tray line, clean-up, and dishwashing. Cross-training these employees is often necessary to allow cook’s helpers and dietary aides to perform more skilled functions when they must fill in for cooks and helpers because of sickness and when cooks and helpers need time off.

During meal service, certified nursing assistants (CNAs), preferably with additional help from volunteers, serve meals and drinks to the residents. CNAs are also responsible for collecting trays and dishes after each meal and for bringing them to the dishwashing area.

Dietary aides operate the dishwasher and clean cooking utensils. Some large facilities have a position of night cleaner who comes in after the kitchen has been closed to thoroughly clean floors; equipment; and other cooking, service, and storage areas.

Dietary Consultation

Therapeutic functions, which include menu planning based on nutritional guidelines, are under the direction of a registered dietitian (RD). Only some very large facilities may be able to afford a full-time RD. When a nursing home does not have an RD on its staff, regulations require the services of a dietary consultant who works under contract. Multifacility chains are likely to have one or more clinical RDs in a corporate-level position to provide consultation to the facilities operated by the chain. The extent and frequency of consultation is specified by nursing home regulations in each state.

The consultant RD must have active involvement in planning menus, developing recipes, ensuring the nutritional adequacy of food served, and assessing nutrition-related resident problems, such as weight loss or feeding issues. The consultant dietitian must also review dietary assessment and care plans, determine equipment needs, review dietary policies and procedures, and make recommendations for sanitary and safe food preparation and storage practices.

After each consultation, the RD must furnish the dietary manager with a written report, and the administrator should receive a copy of this report. The administrator should also have periodic face-to-face meetings with the dietitian to remain involved with any issues or concerns. The consultant dietitian should also meet with charge nurses to address specific patient problems and consult regularly with the director of nursing. Diet and nutritional issues should also be discussed with the patient’s attending physician.

Dietary Screening

Nutritional status of the patient is a critical aspect of holistic care. Determining a patient’s nutritional needs begins with  nutritional screening —identifying patients who may be at risk for nutritional problems. Examples of at-risk patients include those who sustain weight loss, those on therapeutic diets, and those who either cannot take food by mouth or have difficulty eating. Nutritional screening relies on the physician’s diet orders and on a comprehensive screening by the dietitian.

Menu Planning

The menu is central to food service operations because it determines how the resources of the department will be used. Hence, menu planning is a major function carried out with the assistance of the clinical dietitian.

In multifacility chains, menu planning is generally centralized at the corporate office. Standardized menus and recipes are developed for use by affiliated facilities. In this situation, corporations must allow their individual facilities some flexibility for variation to accommodate local tastes. Too rigid a system is likely to result in patient dissatisfaction. In non-chain independent facilities, the consulting dietitian helps the dietary manager develop appropriate menus for the facility.

Three considerations are fundamental to menu planning: meal plan, menu choice, and menu cycle.

Meal Plan

Meal plan  refers to the number of meals to be served per day. The daily nutritional intake should be distributed in a balanced fashion over the number of meals served (Mahaffey et al., 1981).

Conventional Three-Meal Plan

Nursing facilities typically follow a three-meal plan consisting of breakfast, lunch, and dinner (also known as supper). Federal and state regulations specify the maximum time lapse between dinner served at night and breakfast the following morning. A maximum time lapse of 14 hours is the common standard; except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the next day. Regulations also generally require that residents be offered a light bedtime snack, such as crackers, cheese, cookies, ice cream, milk, fruit, or juice. Typically, under the three-meal plan, breakfast is served between 7:30 and 8:30 a.m., lunch at 11:00 a.m. to 12:30 p.m., and dinner at 5:30 to 6:30 p.m.

Modified Five-Meal Plan

A modified meal plan with five daily meals has received enthusiastic acceptance from both residents and caregivers. The extended meal service hours give residents greater access to meals with less disruption of their preferred daily routines. In contrast, under the conventional meal plan, residents need to be up, toileted, and dressed for the scheduled breakfast service. The mornings become the busiest and the most rushed time for the nursing staff, and many patients resist having to get up early in the morning and to be hurried through daily hygiene chores.

Under the modified five-meal plan, a continental breakfast consisting of items such as rolls, muffins, yogurt, custard, juice, and coffee is served at 7:30 a.m. Residents can sleep in if they do not wish to be up that early. By the time a more substantial brunch is served, from around 10:30 to 11:30 a.m., almost all residents are up and around. The other three meals include a lunchtime snack consisting of beverages and high-calorie items served from 1:30 to 2:00 p.m., a regular dinner at around 6:00 p.m., and a late evening snack before bedtime.

Choice of multiple small meals during the day can lead to greater client satisfaction as well as greater nutritional intake. In a study evaluating family members’ preferences for alternatives designed to improve nursing home residents’ oral food and fluid intake, three nutritional interventions were rated as the most desirable: improving food quality, providing feeding assistance, and making multiple small meals and snacks available throughout the day (Simmons et al., 2003).

Menu Choice

The most common type of menu in nursing homes is a  nonselective menu  that does not regularly offer a choice of entrées to all residents. One main dish is specified for each of the three meals. The main dish on the menu is served unless it conflicts with the resident’s preferences as noted in the resident’s records. Regulations require that an alternate food item of equal nutritional value be made available to accommodate individual preferences.

Upscale facilities, with a high proportion of private-pay residents, typically offer a  selective menu  that offers a choice between two entrées from which each resident can make a selection. A full selective menu also generally offers two choices of vegetables and desserts. Offering a selective menu can lower plate waste (food left unconsumed), increase personal satisfaction, and still be accommodated within the food budget. To accomplish this goal, Puckett and Miller (1988) proposed pairing an expensive entrée with an inexpensive one to offset costs. However, a selective menu is likely to require some additional staff time and is more expensive to produce than a nonselective menu.

Another alternative to a selective menu is a buffet offering a variety of food choices. A buffet can also be used as an alternative to a five-meal plan, straddling the hours of the brunch and light lunch services, and offering greater mealtime flexibility to residents.

Menu Cycle

The length of time for rotating the same menu is referred to as the  menu cycle . A set of menus is developed to cover a predefined period, generally 3 or 4 weeks, during which the main items on the menus are not repeated. At the end of this period, the same daily menus are repeated in the same order. Different cycle menus can be created to go with changing seasons. For example, hot soups are more popular in winter, whereas cold cuts and salads go well in summer. Cycle menus do not have to be rigid. There should be flexibility to include festive menus for holidays and other social occasions. Special ethnic themes, such as Chinese, Italian, or Hawaiian, can also be incorporated to break the monotony of regular meal service, especially when special menus are coordinated with social activities promoting some ethnic theme. An outdoor barbecue in summer or a picnic in early fall also add variety to the menu and provide a nonroutine social setting.

Menu Development

Once the meal plan, menu choice, and menu cycle have been established, the clinical dietitian and the dietary manager should work together in selecting appropriate main and side dishes for each meal, based on several factors that include food preferences, nutritional adequacy, appearance and palatability, food cost, and standardized recipes and portions.

General Food Preferences

Food preferences are based on cultural, geographic, and religious traditions. Items selected for the menu should appeal to as many residents as possible, but there is a growing demand to accommodate individual culture-based diet preferences such as vegetarian and kosher diets.

Nutritional Adequacy

Unless a resident has special nutritional requirements, a balanced combination of foods can meet the nutritional needs of most people. The U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (DHHS) jointly publish dietary guidelines to promote nutritional adequacy, including for those at higher risk of chronic disease. The following key recommendations are made in the 2010 Dietary Guidelines for Americans for a reference diet consisting of 2,000 calories per day (USDA/DHHS, 2010):

•  Consume 2 cups of fruit and 2½ cups of vegetables per day.

•  Choose a variety of fruits and vegetables each day. In particular, select from all five vegetable subgroups (dark green; red and orange; legumes, i.e., dried beans and peas; starchy vegetables; and other vegetables) several times a week.

•  Consume 6 oz. of grains, at least half of which should be whole grain products per day.

•  Consume 3 cups per day of fat-free or low-fat milk or equivalent milk products such as yogurt and cheese.

•  Choose 5½ oz. of protein from lean meats and poultry, eggs, fish/seafood, nuts and seeds, and processed soy products.

•  Limit oil intake to 27 grams (a little less than 1 oz.). Solid fats and added sugars should provide no more than 258 calories (13% of total calories).

•  For vegetarians, legumes, nuts, and soy products must be included in meals as appropriate meat substitutes for an adequate intake of proteins. Vegans (vegetarians who avoid eggs and dairy products) should consume calcium-fortified beverages and foods that substitute for milk products.

•  Older adults should also consume extra vitamin D from vitamin D–fortified foods and/or supplements. Assuming minimum sun exposure, adults older than 70 years should take 800 IU of Vitamin D per day.

•  A substantial proportion of individuals over age 50 have reduced ability to absorb naturally occurring vitamin B12, but they can absorb the crystalline form. They should take foods fortified with vitamin B12 such as fortified cereals or take the crystalline form of vitamin B12 supplements.

•  Dietary potassium can lower blood pressure and blunt the effects of salt on blood pressure in some individuals. Other possible benefits of potassium include a reduced risk of developing kidney stones and decreased bone loss. Yet, most Americans do not have enough potassium in their diets.

•  Dietary fiber is important for laxation (bowel movement); the recommended amounts are 25 grams per day for women and 38 grams for men. Beans, peas, vegetables, fruits, and whole grains furnish fiber in the diet.

Dietary Reference Intakes

Before the menus are finalized, their nutrient content must be evaluated to comply with the  Dietary Reference Intakes  (DRIs). The DRIs are a common set of reference values for the United States and Canada and are based on scientifically grounded relationships between nutrient intakes and indicators of adequacy. The primary uses of DRIs are to (1) assess the intakes of individuals and groups and (2) plan diets for individuals and groups. It is important to note that DRI recommendations are for healthy people; they do not necessarily furnish adequate nutrient intakes for individuals who are already malnourished or for certain disease states that may require increased nutrient intake. Age-related declines in nutrient absorption and kidney function may also occur (National Academy of Sciences, 2006). Hence, evaluation of diets and menus by qualified dietitians is critical for making needed adjustments.

Appearance and Palatibility

Pleasing combinations of dishes should be included on the menu by varying color, flavor, texture, shape, consistency, and method of preparation (Graves & Stewart, 1985). Food served to the residents must be both palatable and attractive.

Food Cost

One of the most challenging aspects of menu planning is to keep the cost of food to a minimum without compromising quality. The dietary department is generally allowed a per-patient-day (PPD) cost for the raw food budget. The daily raw food budget will be a dollar amount calculated as follows:

To stay within the budgeted allowance, the daily food cost allowance should first be allocated to each meal and food category. Then the cost of each item on the menu should be calculated (Sullivan & Atlas, 1998). Lunch is generally the most expensive of the three meals, followed by dinner and then breakfast. The cost of bedtime snacks must also come out of the food budget.

Standardized Recipes and Portions

A standard recipe is a blueprint for food preparation and is essential for controlling food cost. Recipes are designed and tested so that a consistent product with known quality, quantity, and taste will be produced. Standard recipes will also yield consistent costs, predictable labor hours, and nutritional value (Ninemeier, 1985). Each recipe must provide details on the specific raw ingredients and their quantity, method of preparing, utensils and equipment needed, method and temperature for cooking, amount of time needed for preparation and cooking, total yield, number of portions, size of each portion, temperature for serving, and any other pertinent information. Recipes based on 100 portions can be easily adapted to serve any number of people. Recipes are commonly printed on plastic-coated recipe cards so that they can be easily filed and retrieved when needed.

Other Factors

Preparation methods, time required for food preparation, skills of the kitchen staff, storage space, serving temperatures, and type of kitchen equipment are things to consider when planning a menu. In other words, facility resources and capabilities must be taken into account.

In addition to the menus included in the regular menu cycle, the facility’s dietary policies and procedures should specify menus for emergency situations such as when the facility has a prolonged power failure or when the dietary department may have to be operated on a skeletal crew because of emergencies such as snowstorms, floods, or other unforeseen events that prevent most of the scheduled staff from getting to work. Under these conditions, preparing the regular menu would be impractical. Emergency menus require the use of canned, preserved, packaged, and precooked food items. The facility must also make prior arrangements for procuring bottled water in case of an emergency.

Purchasing Food and Supplies

Vendor Arrangements

The facility should make arrangements with reputable food vendors to procure dry goods, frozen foods, fresh produce, and dairy products. Several vendors should be asked for competitive bids based on written specifications. Reliability, regular delivery schedule, consistent quality, and price are important considerations when selecting vendors. Depending on the location of their facilities, multifacility chains often have a great deal of purchasing power to select the vendors that their affiliated facilities are required to use. Independent facilities and small chains can explore the possibilities of participating in cooperative or group-purchasing arrangements, such as  group purchasing organizations  (GPOs) that can give even small facilities extraordinary buying power. A GPO is a company that pools together the combined buying power of its members to negotiate substantial discounts from vendors.

Food vendors have different grades of products to meet the needs of a variety of customers. For instance, quality can vary according to brand, grade, size, thickness, weight, or count. Because of these variations, a facility ought to have written specifications for the food it buys as part of its contracts with vendors or GPOs.

Food Ordering

The planned menu and recipes provide the basis for food purchasing. However, careful planning is necessary to ensure that the needed food items will be available in time for food production. Size of the order is governed by the patient census, anticipated number of guest meals, and meals for volunteers and staff. In essence, the number of portions to be served must be carefully forecasted, and the time lapse between food delivery and preparation must be taken into account. The frequency of delivery depends on the vendor’s delivery schedule, the type of food item delivered, and the facility’s storage capacity. Puckett and Miller (1988) suggested the following steps for economical food delivery:

•  Frozen food: weekly or semimonthly

•  Chilled meat, fish, and poultry: twice a week

•  Fresh produce: once or twice a week

•  Canned goods and staples: weekly, semimonthly, or monthly

•  Fresh dairy items, breads, and baked goods: daily or every other day

•  Butter, eggs, and cheese: weekly

Dietary Supplies

Supplies used in the dietary department can be classified into three main categories: supplies used in the kitchen for food production, such as aluminum foils, plastic wraps, and storage bags; supplies used for serving meals; and chemicals and supplies for dishwashing and cleaning. Supplies used for food service can be categorized as reusable or disposable. Such supplies include trays, dinnerware, tableware, hollowware, glassware, and disposable paper, plastic, and styrofoam products.

Reusable supplies come in a variety of materials, such as rubber, plastic, fiberglass, and other materials, such as vitrified china, which is designed for both durability and attractiveness. Stainless steel cutlery resists tarnish, is durable, and is easy to clean. Some disposables, such as paper napkins, may be used on a regular basis, but they are mostly kept on hand for emergency use. An adequate amount of disposable plates, cups, and cutlery should be kept in stock to be used when a power outage occurs or when the dishwashing equipment is out of order. Regular use of disposables in the long run is quite expensive, yet it comes across as “cheap” to residents and visitors and diminishes the aesthetic appeal of the dining experience. Tablecloths, cloth napkins, and table centerpieces used at least for the main meal add to the quality of the dining experience.

Food Storage and Inventory

Receiving

The dietary department should have control procedures to ensure that the food and supplies delivered by vendors match the quality and quantity of items ordered. Dietary policies should assign the job of receiving to authorized personnel, and receiving responsibilities and procedures should be clearly described. Two receiving methods are commonly used (Puckett & Miller, 1988): invoice receiving and blind receiving.

Invoice Receiving

Invoice receiving  is a method in which the items delivered are checked against the original order. The focus is on finding any discrepancies between what was ordered and what is received. Shortages, substitutions, deviations from quality specifications, and any rejections should be carefully noted by the receiver.

Blind Receiving

Blind receiving  is a method in which the original order shows the specific items but not the quantities; the quantities received are recorded by the person checking the order. This method is more reliable than invoice receiving because the receiver may fail to do accurate comparisons when using the invoice receiving method. In either case, the facility should use its own ordering record rather than the supplier’s delivery invoice to ensure that all items received are exactly as they were ordered.

Storage

The facility should have adequate, secure, and sanitary space for storage of various food items at their proper temperatures. Three types of food storage space are necessary: dry storage, refrigeration, and freeze storage.

The dry storeroom must be clean, cool, and dry. It should also have adequate ventilation and lighting. The recommended temperature range for dry food storage is between 50° F and 70° F (10° C to 21° C) (Puckett & Miller, 1988). All food must be on shelves or kept above the floor on dollies or pallets, which should be 6 to 12 inches above the floor, depending on state regulations. Off-the-floor storage enables the entire floor area to be kept clean. Chemicals and cleaning supplies should be stored in a separate room or closet.

Refrigerator temperatures should be maintained at 40° F (4° C) or lower. To prevent cross-contamination, raw meat should be separated from other foods and should be stored on the bottom shelves so meat juices do not drip on other foods.

Frozen foods should be kept at 0° F (–18° C) or below. Refrigerators and freezers should be equipped with functioning thermometers. A temperature log should be maintained to record regular temperature readings for refrigerators and freezers. Any malfunctions should be reported to the maintenance department for prompt repairs.

Inventory Control

Determining how large a food inventory should be on hand at any given time depends on two main factors: immediate needs and contingency needs. A sufficient stock of food must be on hand at all times to prepare meals for the next 4 to 7 days, depending on the ordering cycle.

In accordance with the policy on emergency menus, adequate nonperishable food items must be held in stock to last for 3 to 4 days. State regulations may also specify how many days worth of food inventory and nonperishable emergency food supplies must be maintained.

Two methods of keeping track of inventory are used conjointly for adequate control: the perpetual inventory system and the physical inventory system.

Perpetual Inventory System

A  perpetual inventory system  is used to maintain a continuous record of the quantity on hand for each item. A separate inventory record is maintained for each item. Modern scanning and inventory software technology has greatly facilitated maintaining a continuous record of inventory. In small operations cards can be used, which need to be updated each time items are added or taken out. This can be time consuming. Perpetual inventory is kept up to date as follows:

This system provides a running balance of quantities remaining on shelves at any given time.

Physical Inventory System

In the  physical inventory system , each item in storage is actually counted, generally once a month. Physical inventory gives an accurate count of what is on hand. The quantities on hand should tally with the amounts on hand shown in perpetual inventory. Discrepancies may suggest either pilferage or errors in recording data (Sullivan & Atlas, 1998).

Rotating the inventory is important to prevent spoilage. The first-in first-out system, abbreviated as FIFO, requires that all products be dated when received. Secondly, newly received products should be stored at the back of the shelves; products already on the shelf should be moved to the front. When products are needed for food preparation, they should be picked from the front. This system ensures that older products are used first.

Food Costing

All facilities should at least take a monthly physical inventory to accurately determine the food cost, which is calculated as follows:

(a)  Cost of physical inventory at the end of the previous month

+

(b)  Cost of all food invoices (food purchased) during the current month

−

(c)  Cost of physical inventory at the end of the month

=

(d)  Gross food cost for the month [(a) + (b) − (c)]

−

(e)  Cost of meals served to nonpatients:

(f)  Net patient food cost for the month [(d) − (e)]

(g)  Food cost per patient day (PPD):

Note: Patient days = Cumulative census for the month

A high food cost does not necessarily indicate that the food being served is of high quality. The dietary manager must always be conscious of food waste and the potential for pilferage. Periodic monitoring of receiving procedures and regular checks of receiving and storage areas can reveal problems that may otherwise go unnoticed. Food in poor condition may have to be discarded, but the department must have a strict policy that no food is to be discarded without specific approval from the dietary manager. Ordering foods not called for by the menus, ordering in excessive quantities, and overproduction are other factors that often lead to waste and higher food cost than what is necessary. Theft and pilferage may be occurring that may go unobserved. The dietary manager should do occasional spot checks to reconcile invoiced and received items.

The administrator should be aware that even though the dietary manager and his or her assistants have the responsibility for controlling dietary products, the supervisors may themselves be involved in theft. This consideration does not automatically imply guilt, but it should increase awareness of the possibility of theft by supervisors. Precosting menus establishes the expected food cost. When the actual food cost substantially exceeds or routinely exceeds the expected cost, the administrator should first look into the methods being used for inventorying food and calculating the food cost before investigating probable breaches of security.

Food Production

Production Planning

Food production requires planning ahead. For instance, frozen meats must be thawed in the refrigerator 3 to 4 days in advance so that they are available for cooking on the day they are on the menu. Some food items require full or partial cooking on the day before the menu is to be served. However, in spite of the best planning efforts, some deviation from the menu may sometimes become necessary. For example, an item needed for the menu might not be received on time, or the quantity of raw ingredients on hand might not be sufficient. In such cases, occasional substitutions become necessary and the facility must make contingency plans, because the need for substitutions generally crops up at the last moment. Menu substitutions should match the nutritive value of the food item replaced, and all substitutions should be properly documented.

Production Methods

Three basic types of food preparation methods are commonly used in health care institutions (Puckett & Miller, 1988). Each method has its advantages and disadvantages, which should be carefully evaluated during menu planning.

Cook-and-Serve Method

The cook-and-serve method is the traditional approach to food production, in which most menu items are prepared primarily from raw ingredients on the day they are to be served. After cooking, the food is kept hot or cold until serving time. Cook-and-serve requires a relatively large inventory and more labor than the other two methods. Another disadvantage is the limited time the staff generally have to get the food ready for serving. Greater control over quality is one of the main advantages. Food cooked from scratch has “home-cooked” appeal. Use of seasonal fresh produce makes food even more appealing. Home-style cooking can be marketed to prospective clients as an added value. Some facilities prepare fresh bakery items, such as breads and pies, on a daily basis. The pleasant aroma of freshly baked goods permeating throughout the facility appeals to most people, and it adds to the homelike atmosphere. This aroma can be easily achieved by using premixed products, which are widely available in dry or frozen form.

Cook-and-Chill or Freeze Method

Chilling or freezing after cooking requires two stages of heating: initial cooking and reheating before serving. The cooking stage can be done up to 6 weeks in advance for cook-and-chill items, and earlier for cook-and-freeze items.

In the cook-and-chill method, the food is first completely cooked. It is then rapidly chilled to between 33° F (1° C) and 38° F (3° C), using an ice bath or blast chiller. Typically, complete chilling is accomplished in 90 minutes to 2 hours. The food is then stored in a chilled storage cabinet until it is ready to be served, when it is reheated to a temperature of 165° F (74° C).

The cook-and-chill and cook-and-freeze methods are similar in all respects except that the latter involves freezing the food to 0° F (−8° C) or below. Cook-and-freeze requires a fast-freezing unit and special packaging, both of which increase the cost. One major advantage of cook-and-freeze items is that they can be kept on hand for contingency use or be used during a subsequent menu cycle. Frozen cooked foods must be thawed in the refrigerator or in the microwave, never at room temperature because it promotes the growth of illness-causing bacteria.

Incorporating these methods is also helpful when selective menus are offered. Menus can be planned in such a way that low labor productivity (slack time) on certain days can be used to prepare additional items to be served on a later day. Another major advantage is that chilled or frozen foods are less perishable and retain nutrients longer than foods cooked and held at serving temperatures for relatively long periods in the cook-and-serve systems. The freezing process does not destroy nutrients. One major drawback is that not all chilled and frozen foods can be successfully prepared without extensively modifying the ingredients or recipes. Certain foods lose their flavor or texture after freezing. Such foods include vegetables such as cabbage, cucumbers, lettuce, and radishes; foods with eggs or milk; and mayonnaise, gelatin, and salad dressings. Limited refrigeration and freezer space presents additional obstacles.

Assemble-and-Serve Method

This method is also called the “convenience system” because only minimal food preparation is necessary. The foods are commercially prepared and packaged. Depending on how they will be used on the menu, a variety of prepared products can be purchased in fresh, frozen, canned, or dehydrated forms. Menu variety is often greater in assemble-and-serve systems than in most cook-and-serve systems. But inconsistent quality and greater upfront expense are the main drawbacks. Despite its advantages, the higher cost of assemble-and-serve products cannot be justified unless it reduces labor costs.

Modified Diets, Supplements, and Nourishments

A regular well-balanced diet is the most appropriate diet for most elderly patients. Certain medical conditions, however, necessitate diet modification or supplementation. Nutritional needs can also be altered by disease, stress, and drugs. The need for modified diets or food supplements should be evaluated jointly by the dietitian, nurses, and the patient’s attending physician.  Modified diets  are therapeutic diets aimed at addressing a health condition.

Simple Modified Diets

In most instances, only minor modifications of the regular menus are necessary. For instance, a mechanical soft diet is produced by simply grounding or chopping the food so it requires minimum chewing. For a puréed diet, the regular food is pulverized to a puréed consistency, using a food processor. These are the simplest types of therapeutic diets.

Restricted diets are also relatively simple modifications of regular menu items, and these diets generally require restricting or eliminating certain condiments. For example, in a sodium-restricted diet, salt and processed foods that may have a high salt content are restricted. In a bland diet, irritants such as caffeine and spices are left out. A low-cholesterol diet requires restricting foods rich in saturated fats.

Sometimes, serving therapeutic diets becomes a balancing act. On the one hand is the need to incorporate restrictions from a purely dietary standpoint. On the other hand is the compromised palatability of a diet that can become a little too restrictive, which may in turn contribute to poor nutritional intake. Relaxing the restrictions in some modified diets—sometimes referred to as a  liberalized diet —may help prevent malnutrition. The risks and benefits should be carefully weighed, especially when a resident’s nutritional status is already compromised (Aldrich & Massey, 1999).

Complex Modified Diets

More complex diets than those just described call for substituting certain items on the regular menu and may need rebalancing of nutritional values. Examples include low-fiber and high-fiber diets in which appropriate foods must be added or eliminated from the diet. A diabetic diet requires a careful balance of carbohydrates, proteins, and fats, and sugar substitutes are used in place of natural sugars. High-carbohydrate and high-protein diets also must be carefully balanced. Clear-liquid and full-liquid diets are based on a judicious selection of appropriate liquids such as clear broths and gelatin-based products. Certain food allergies or food intolerances also call for appropriate substitutions.

Nutritional Supplements

Commercially prepared oral formulas, called  supplements , are used for patients who may not be eating enough to get balanced nutrition. Oral supplements have been formulated to meet almost any type of special nutritional requirement. Examples include nutritionally complete puddings, calorically dense supplements, or protein supplements (Gerwick, 1992). Appropriate supplements are prescribed for residents with actual or potential weight loss, wounds, and nonhealing pressure ulcers (McDaniel, 2014). For most patients, unless special nutritional issues exist—as when regular food intake becomes a chronic issue—use of supplements should be restricted.

Nourishments

Nourishments  consist of light foods or snacks that are served in between the main meals, generally 2 to 3 hours after a regular meal. A nourishing snack must be offered to all patients before bedtime, although many patients do not desire it. During the day, however, most patients do not require additional snacks if they have adequate food intake. Snacks may actually diminish a person’s appetite for consuming the regular meals. Yet some patients may not be consuming the regular meals properly when depression, certain medications, and difficulty in chewing or swallowing may curtail a person’s appetite.

Food Acceptability and Intake

Maintaining nutritional content and ensuring the patient’s acceptance of the diet are the biggest challenges in preparing special diets. It can be argued that overly rigid enforcement of a dietary regimen may not be in a patient’s best interest if the patient will not consume the food and will remain unhappy. Imposing severe restrictions may lead to stress, anger, anxiety, or depression (Robinson & Leif, 2001). Such issues should be resolved by the multidisciplinary team, in consultation with the patient’s attending physician. In recommending therapeutic diets, the potential benefits must be evaluated against the possible detriments to optimal food intake and the disruption in the resident’s quality of life (Gerwick, 1992). The patient is responsible for following the recommended nutrition care plan, but also has the right to refuse medical treatment, including a therapeutic diet. But if the resident refuses to follow the nutrition care plan, he or she bears the responsibility for any adverse consequences. However, such incidents must be addressed in care-plan meetings and carefully documented in the patient’s medical record. The documentation should specify what efforts the staff may have made to try and persuade the patient to follow the dietary regimen.

Food intake problems are also related to a decline in self-feeding skills or improper positioning while eating. Such problems should be evaluated by an occupational therapist (OT), who may recommend proper positioning or adaptive tableware to improve a patient’s self-feeding skills. Problems related to swallowing should be addressed by a speech/language pathologist.

Food intake and plate waste must be documented for each patient. The multidisciplinary team should also evaluate any food acceptance problems. Simply reevaluating a patient’s likes and dislikes and providing appropriate substitutes can solve some food acceptance problems. Widespread plate waste among residents often indicates poor choice of foods for the resident population or preparation methods that most people do not like. In such cases, menus must be revised. Such issues can be best addressed through the resident council and call for prompt action before the meals become a pervasive cause for discontentment.

Eating Issues with Dementia Patients

Because of cognitive, physical, and psychological problems, individuals with dementia often need extra care. Dementia patients may have difficulty initiating the feeding tasks; problems with chewing or swallowing; or other mealtime issues such as wandering, pacing, refusal, or apathy (Chang & Roberts, 2008). Hence, effective intervention techniques become necessary, realizing that there will be individual differences and not all interventions will work for everyone. Use of supplements or between-meal snacks can be beneficial. However, other types of interventions, such as staff training, assistance with feeding, and modification of the environment and routines have been found to be effective. For example, switching between high-contrast red and high-contrast blue tableware increased food intake in one study (Dunne et al., 2004). Playing relaxing music at mealtime may decrease agitation and other behaviors (Hicks-Moore, 2005). Use of reminiscence conversation and verbal prompts encouraging the patient to eat may also be helpful (Cleary et al., 2012). Sharing mealtimes between residents and caregivers has also been shown to produce positive results, such as weight gain (Charras & Frémontier, 2010); meal sharing is a common culture change practice in Green Houses. Dementia patients tend to gravitate toward their original culture values and patterns. Hence, people with dementia might not like the taste of modern cooking; they may prefer more traditional recipes (Calverley, 2007). For the same reason, family-style meals that characterize their culture of origin will be more beneficial than congregate meals to residents with dementia (Charras & Frémontier, 2010).

Intensive Nutrition

Intensive nutrition support, commonly called tube feeding, may be necessary for patients who are unable to maintain adequate food intake with either a regular or a modified diet. Conditions that may require tube feeding include protein-energy malnutrition, liver or kidney failure, coma, or dysphagia because of stroke, brain tumor, or head injury. Although the care and monitoring of feeding tubes is a nursing responsibility and not something overseen by the dietary staff, intensive nutrition is discussed here because it is an integral part of meeting patients’ total nutritional needs.

Enteral and parenteral nutrition are two types of intensive feeding methods; which one is used depends on the patient’s condition. The dietitian, nurses, and the attending physician determine what the patient’s medical needs are, and they also determine the appropriate method of nutrient delivery.

The cost of commercially prepared enteral and parenteral formulas is generally not regarded as a food expense. This cost is best classified as a separate line item on the budget, either under the nursing department or under the dietary department. To correctly calculate the regular food cost, the number of patient days incurred by patients receiving intensive nutrition should be subtracted from the total number of patient days (see the section on Food Costing).

Enteral Feeding

Enteral feeding  is a method of delivering liquid food directly into the stomach through tubes. There are two common types of tube feeding: a nasogastric tube (NG-tube) passes through the nasal openings, down the esophagus, and into the stomach; a gastrostomy tube (G-tube) passes through a surgical opening in the abdomen. Enteral feeding is a safe method of providing nutrients to patients who have a normally functioning gastrointestinal system but who cannot eat normally. Depending on the patient’s medical needs, tube feeding may be necessary for only a short time, or permanently.

Enteral feeding may be used as the sole source of nutrition or as a supplement to inadequate oral intake. Commercially prepared liquid formulas are used according to the patient’s nutritional needs. The formula is either delivered through a small bedside pump or it is allowed to drip naturally into the tube. In other instances, puréed or liquefied foods may be used, requiring special preparation by the dietary department.

Parenteral Feeding

Parenteral nutrition  is a method of delivering balanced nutrition directly into the bloodstream. A special liquid formulation, called total parenteral nutrition (TPN), is infused into the bloodstream by inserting a catheter in a central or peripheral vein (Robinson & Leif, 2001). The process must be carefully monitored by licensed nurses. Parenteral nutrition may be necessary in cases of severe malnutrition or when the patient’s gastrointestinal tract is not functioning properly.

Food Service

Centralized and Decentralized Systems

Tray service is the most common method of serving food to residents in nursing facilities. Most facilities use the system called centralized meal service in which all trays are assembled at the kitchen service line. At meal time, the food service station is staffed by several kitchen workers in order to minimize the serving time.

Another system that may be appropriate for some facilities is decentralized meal service, in which food produced in the main kitchen is transported in bulk to various smaller dining locations where the food is portioned and served. For example, the household architectural design with decentralized dining rooms requires this type of food service. The service can be modified if the serving location has an auxiliary kitchen, which can be furnished with salad, beverages, and bread. In this case, the main dish and vegetables are prepared in the facility’s central kitchen, and food is transported in bulk to individual dining areas. The food is kept hot on steam tables from where it is dished out on plates and served family style, eliminating tray service (Noell, 1995). Even when tray service is used, some facilities have improvised family-style dining by taking the plates off the trays while serving. Thus, instead of putting a tray in front of the resident, food and beverages are placed before the resident in individual plates and glasses.

Positive nutritional and clinical outcomes can result by changing from a centralized food-delivery system to a decentralized system. Portioning food in the residents’ dining room (as opposed to the kitchen) encourages increased food consumption, which can contribute to residents’ improved nutritional status. Studies have reported that family-style meals stimulate daily energy intake and protect nursing home residents against malnourishment (Nijs et al., 2006; Shatenstein & Ferland, 2000). However, before implementing a decentralized service, managers should take into consideration concerns of employees who may experience frustration because of increased demands on their time, as one Canadian study pointed out (Shatenstein et al., 2001).

Noell (1995) reported that serving meals in “neighborhood” family-style settings also resulted in cost savings by reducing waste and by curtailing the need to provide nutritional supplements because of low food intake. Hence, evaluating the cost-benefit aspects of these alternative service methods is necessary. For example, cost savings from reductions in the use of nutritional supplements or an increased facility census because of better perceived value by prospective clients may compensate for increased spending on family-style table service.

Food Service Station

In traditional tray service, the food service station is a food holding and food assembly area. As each tray is assembled, a nonpowered conveyor system moves the trays on rollers from the serving area to a platform where they are picked up by the serving staff.

In efficient kitchen design, the food service station is located between the food production and tray pickup areas. Cooked food is transferred from the cooking area to the service station where all foods are maintained at appropriate temperatures and assembled for service to patients. Any cold food is put on the plate first, and then the plate is moved to the hot section where hot food is dished out from a steam table. Infrared lamps are also used to keep certain foods hot. Holding wells in the steam table are replenished as needed. The recommended holding and serving temperatures are ≤ 40° F (5° C) for cold foods, and ≥ 140° F (60° C) for hot items. Clean thermometers must be used to periodically monitor food temperatures during meal service. The holding equipment is not meant for reheating food, only to maintain food at the right serving temperature.

All food service staff must be trained in portion control. Standardized recipes establish the size of portion to be served for each food item. Measuring scoops, ladles, serving spoons, food-weighing scales, and other serving equipment are essential for portioning food. Some food items are prepared in predetermined portions, which makes service both quicker and easier.

Accuracy

Individual trays are assembled using a diet card or diet ticket for each patient. Diet tickets are now generated by computerized systems, whereas diet cards are used in the manual system. The diet cards are updated to reflect any changes in diet or food preferences. To minimize diet errors, a trained individual must work at the end of the tray line as a checker. The checker is responsible for ensuring that the food items on the patient tray are what should be on the tray in accordance with the diet orders, individual preferences, and any contraindications noted on the patient’s diet card.

Food Transportation Systems

In larger facilities, if centralized tray service is used, food often must be transported from the kitchen to auxiliary dining rooms located away from the main kitchen and dining areas. In this case, food is dished out in the main kitchen where the diet cards are maintained. The trays are loaded onto enclosed carts, which are transported to auxiliary dining areas. The challenge is to maintain foods at their right serving temperatures. To facilitate this goal, a variety of food transportation systems are available. Heated pellets have been in use for a long time. A pellet is a metal plate that requires heating in a pellet dispenser before the food plate is placed on the heated pellet. The pellet system requires removing the hot pellet before serving the tray to prevent burns to residents. To overcome these drawbacks, insulated trays with hot and cold compartments can be used. With either the pellet system or the insulated tray system, basic transportation carts are used. These carts do not have heating or refrigeration capabilities.

Carts with temperature controls are equipped with heating and refrigeration mechanisms. Specially designed split trays can slide into a cart that has hot and cold sections. In this system, half the tray is held in a heated compartment and the other half in a refrigerated compartment. All hot foods are placed on one side of the tray, and cold foods are placed on the other side of the tray. A major drawback of all food transportation carts is the difficulty of maneuvering them because of their heavy weight (Greathouse & Gregoire, 1997). Accident prevention through proper training becomes essential.

Finally, specialized trays can be used with rethermalization carts. The trays have special cutout areas for entrée, soup, and vegetable dishes so that, when the trays are loaded onto the rethermalization carts, the dishes make contact with the conduction heat element in the cart (Greathouse & Gregoire, 1997).

When properly used, all of these systems can work quite satisfactorily. But each system has its own advantages and disadvantages, which must be carefully evaluated by the administrator and the dietary manager when deciding on which system to use.

The Dining Experience

Dining plays a critical role in a resident’s quality of life because most residents look forward to mealtime. A satisfying experience can also improve clinical outcomes through better nutrient intake. Jackson (2003) pointed out that dietitians and food service managers who routinely circulate in dining rooms during mealtime can gather a wealth of information by simply observing and talking to residents. Such observation can reveal, among other things, which menu items are well accepted, whether the food presentation is attractive, whether personal food preferences are respected, whether diet orders are being followed, and whether portion control standards are adhered to. Similarly, the nursing staff should ensure that patients are properly positioned while eating. Inappropriately positioned patients can aspirate, experience difficulty eating, or get tired and frustrated (Jackson, 2003).

Food Safety and Sanitation

Promoting food safety and preventing food-borne illnesses are of critical importance in nursing facilities. Compared with the general population, residents in nursing homes are more susceptible to illness and may exhibit more severe adverse outcomes when they are ill. An outbreak of disease can place severe burdens on the nursing home staff and result in much adverse publicity in the community. Yet, food poisoning is almost entirely preventable by practicing good sanitation and good food handling techniques.

All staff members involved with the handling, cooking, and service of food must receive training in food sanitation and safety. Hygienic practices, such as hand washing, cleaning and sanitizing equipment and food preparation surfaces, and washing fresh produce and meats before use must be enforced by management. All staff members must wear appropriate head covering. The dietary department must also have written policies on food safety, and the staff must be trained on the proper storage and use of cleaning chemicals.

Food-borne illnesses can result when food is contaminated by bacteria, viruses, parasites, or chemicals. Bacterial infection is the most common cause of food-borne illness because bacteria can easily grow and produce toxins in foods. Almost half of all bacterial outbreaks (incidents involving two or more single cases) are the result of cross-contamination (Cody, 1997). Common examples of cross-contamination sources include using the same knife or cutting surface to prepare raw and cooked foods, using a contaminated sink for thawing frozen meats, and unsanitary food handling. Flies, cockroaches, and rodents can transmit pathogens (disease-causing organisms) to food. Therefore, pest control by a reputable firm is an essential part of food sanitation.

The most common illness-causing bacteria include Salmonella, Clostridium botulinum, and Escherichia coli. They can be destroyed by heat. Hence, internal temperatures in meats should be monitored using a probe thermometer during cooking. Beef, veal, and lamb should be cooked to an internal temperature of 145° F (63° C); pork and ground meats to 160° F (71° C); and poultry to 165° F (74° C) (USDA, 2006). Staphylococcus aureus is another organism that can be destroyed by heating, but the toxins that are produced in food are relatively heat stable. Therefore, practice of food hygiene by all associates is essential.

Maintaining proper food holding temperatures is critical because bacteria thrive best at temperatures between 40° F (5° C) and 140° F (60° C), the range regarded as the  temperature danger zone . In the temperature danger zone, bacteria can double in number in as little as 20 minutes (USDA, 2006). In general, food should not be held at room temperature for longer than two hours. Simply reheating food that has been left out for that long may not destroy pathogens if they are present (Cody, 1997).

Another frequent cause of temperature-related food-borne disease is improper cooling when cooked food requires storage. Leftover foods must be quick cooled and refrigerated within 2 hours. Refrigerators should be maintained at a temperature no higher than 40° F (5° C). Before serving, foods should be reheated to an internal temperature of 165° F (74° C) (USDA, 2006).

Proper dishwashing procedures for cleaning and sanitizing tableware and kitchenware are also critical. A three-compartment sink for washing, rinsing, and sanitizing is recommended for handwashing utensils and equipment. Sanitizing can be achieved by immersion in hot water at 170° F (77° C) or by using chlorine or iodine at recommended strengths. The recommended temperatures for mechanical dishwashing are 140° F (60° C) for wash, 160° F (71° C) for rinse, and 180° F (82° C) for final rinse and sanitizing (Sullivan & Atlas, 1998). Dishes and utensils should be left on racks to air dry. Wiping with cloths can result in cross-contamination.

Terminology for Review

blind receiving

Dietary Reference Intakes

enteral feeding

group purchasing organization

invoice receiving

liberalized diet

meal plan

menu cycle

modified diets

nonselective menu

nourishments

nutritional screening

parenteral nutrition

perpetual inventory system

physical inventory system

selective menu

supplements

temperature danger zone

For Further Thought

  1.  What can the administrator of a nursing facility do to minimize pilferage of assets such as supplies and food?

  2.  Discuss some factors that should be evaluated to determine the costs and benefits of providing family-style meal service in a nursing facility.

Case 1

Unhappy with Mechanical Soft Diet

Contributed by Julie McCullough, PhD, RD; Katie Ehlman, PhD, CHES, HFA; Elizabeth Ramos, MS, RD, CD; and Mary Kay Arvin, OTD, OTR, CHT, College of Nursing and Health Professions, University of Southern Indiana.

After a 5-day hospitalization subsequent to a heart attack, 82-year-old Mr. Lee has been admitted to a nursing home. The admitting physician prescribed a low-fat, low-sodium diet. On assessment at the nursing facility, Mr. Lee was found to have trouble chewing food due to poor dentition (missing teeth and partial dentures that do not fit well). The nurse called the physician and had the diet order changed to a mechanical soft* low-fat, low-sodium diet. Also, because of some issues with choking, the speech therapist conducted a swallowing study, which revealed nothing wrong. The therapist, however, thought that the mechanical soft diet would minimize the risk for choking.

Today, the consulting dietitian is visiting Mr. Lee at lunch time in the dining room. The dietitian notices that the resident tires easily when eating. Mr. Lee expresses dissatisfaction with the mechanical soft diet. He refers to it as “dog food” but adds that in his culture food is never wasted. So, he feels obligated to eat it all even though he does not like it. He would like to have the regular food he could order when he was in the hospital.

Questions

1.  How should the dietitian address Mr. Lee’s dissatisfaction with food?

2.  Would it be appropriate to liberalize Mr. Lee’s diet?

3.  What should the facility do if Mr. Lee simply returns his food to the kitchen?

*Mechanical soft diets are designed for people with chewing problems due to missing teeth, oral issues such as surgery, or fatigue when chewing food.

Case 2

Complaints About Dietary Services

Contributed by Cindy K. Manjounes, MHA, EdD, Lindenwood University.

Complaints from residents have started to surface regarding availability and selection of items on the menu. Residents on restricted diets as well as vegetarians have limited choices. The facility offers a nonselective menu, but, to the extent possible, accommodations are made. Recently, meal hours have been reduced because of staff shortages in the dietary department. The administrator was invited to this month’s resident council meeting in which some residents became emotional, and the council’s president stated, “We used to look forward to meal times, but things have gone downhill. The hours have been cut and we are rushed through the meals. Some of us are thinking about moving to another facility even though we like the nurses here. They are really caring. We have heard that the home has a new food service manager. This person needs to straighten things out before we all leave.” Attendance in the dining room has dropped because residents have started to request in-room meal delivery so they can take the time to eat their meals. Some CNAs have been grumbling about the extra work they have to do to deliver meals and pick up afterwards.

Questions

1.  Identify the main issues that need to be addressed. What may have caused these problems?

2.  Prioritize the issues based on their potential impact on the residents, staff, and the facility.

How should the administrator go about addressing the issues?

FOR FURTHER LEARNING

Dietary Guidelines for Americans, 2010. Jointly published by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services.

http://health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf

REFERENCES

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Shatenstein, B., & Ferland, G. (2000). Absence of nutritional or clinical consequences of decentralized bulk food portioning in elderly nursing home residents with dementia in Montreal. Journal of the American Dietetic Association, 100(11), 1354–1360.

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U.S. Department of Agriculture. (2006). Safe food handling: How temperatures affect food. Washington, DC: Author. Retrieved January 2009 from http://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-food-handling/how-temperatures-affect-food/CT_Index.

U.S. Department of Agriculture/U.S. Department of Health and Human Services. (2010). Dietary guidelines for Americans, 2010 (7th ed.) Washington, DC: U.S. Government Printing Office.