Long-Term Care Survey Alert

Surveyors are waving an MDS in your face, claiming it doesn't paint an accurate picture of the resident, which signals problems with your careplan or even a false claim for services.

Don't panic. There may be some perfectly understandable reasons why various MDS items don't jibe with each other or with the medical record.

Five legitimate reasons for MDS inconsistencies include the following, according to Beth Klitch, principal of Survey Solutions in Columbus, OH, who spoke at last month's American Health Lawyers' "Long-Term Care and the Law" conference in Phoenix:

1. MDS coding instructions that differ from accepted standards of practice. The prime example: MDS instructions directing providers to downstage a pressure ulcer, which runs contrary to every other accepted standard of practice. Thus, the MDS might refer to a Stage 2 ulcer while all the other documentation tags a healing wound as Stage 3 or 4.

2. Minor mistakes. Did someone simply code the wrong dates or numbers, which can be confirmed and clarified by referring to the clinical record or other documentation?

3. Instances where the resident refused treatment for his condition. But watch out if the resident is coded at Section B4 as moderately or severely impaired in daily cognitive decision making or as having signs of depression in Section E. Surveyors or plaintiffs' attorneys might question whether residents with these conditions are able to make such decisions on their own behalf. (For more information, see the Reader Question on in article 8.)

4. Variances in resident functioning at different times of the day or in different settings. Does the resident behave much differently at night, for example, when he becomes more confused?

Interrater reliability can also result in inconsistencies, says Barbara Nodiff, a nurse consultant with Associated Geriatric Information Network in New Rochelle, NY. "With a change in assessors, we often find the changes in scoring activities of daily living and you have to figure out why and which assessor is accurate," Nodiff says.

Yet you might find that a discrepancy between the MDS and medical record documentation legitimately reflects how two disciplines for example, nursing and rehab therapysaw the resident perform in different settings.

Or nurses who are accustomed to the resident and a social worker who doesn't see the resident as frequently might have different impressions of the resident's mood and behavior.

5. Different look back periods. Do the sections portraying the resident differently measure different time frames? As Klitch notes, some assessment items have a much longer lookback period (30 days as opposed to seven days), which could explain seeming inconsistencies among various MDS sections.