Rose Ann DiMaria-Ghalili and I used a 2000 revision of the 2.0 version of the Minimum Data Set (MDS) user's manual as the first source for this information. But since the Centers for Medicare and Medicaid Services regularly revises the MDS manual, we checked its Web site for the most recent documents and found a version revised in December 2002 (see http://www.cms.hhs.gov/quality/mds20). The revised Appendix C states: "Malnutrition problem suggested" if one or more factors is observed, including "leaves 25% or more food uneaten at most meals."

I agree that the recommendations that we set forth on checking dietary records and performing a full assessment are not cited in the manual and its updates, and I apologize for making it appear that these were regulatory requirements. However, it would be difficult to determine that malnutrition is or is not present unless these activities (and others) were carried out.