MDS Alert

Put these key sections and items under the forensic lens.

The MDS can provide key clues when you're sleuthing a potential case of abuse or neglect.

Case in point: Suppose you're evaluating bruising of unknown origin. Look to see if the resident has abnormal labs such as elevated protimes (P9), diseases in Section I or treatments that could cause him to bruise with minimal trauma.

"Someone taking Coumadin is more likely to bruise with minimal trauma," says Barbara Bates-Jensen, RN, PhD, CWOCN, a nursing professor at the UCLA School of Nursing and School of Medicine and VA GLA Geriatric Research Education Clinical Center.

Or if the person is receiving chemotherapy for cancer (Section P1a), the person may have low platelets, which lead to bleeding or bruising. Also, anemia (Section I) makes a person more likely to bruise and be lethargic, as well as prone to falling, Bates-Jensen says. Dialysis patients have more fragile skin and can be more likely to get skin tears and bruising, says Gail Robison, RN, a consultant with Boyer and Associates in Brookfield, WI. "People with edema (Section J) are also more prone to skin injury."

Osteoporosis (Section I) can result in unexplained fractures. "Twisting motions, such as pivoting in a transfer, can cause fractures in severely osteoporotic individuals," says Charles Crecelius, MD, PhD, a medical director in St. Louis, MO.

A resident may have numerous risk factors for osteoporosis coded on the MDS that heighten suspicion she may have the disease (see p. 18).

Other MDS sections and items to consider during an abuse and neglect investigation include:

• Cognitive impairment with agitation or aggression (Sections B and E4). Caregivers may find these residents very difficult to care for and may be reluctant to care for them, Bates-Jensen says. Or a staff person may lash out at a resident who hits or verbally abuses him.

Tip: Compare Sections B, C and E to look for changes from one assessment over time, Robison advises. "A person who is being neglected or abused may show increasing indicators of problems in these areas, including daily decision-making, mood and anxiety."

• ADL function (G1) and weight loss (K3a). When evaluating a resident with significant weight loss who is dependent on CNAs for eating, you should explore how the caregivers are feeding the person, Bates-Jensen suggests. "They may lack knowledge about how best to provide feeding assistance -- or there could be some measure of neglect."

• Section J (stability of conditions and fractures). If you code that the resident has an unstable condition (J5a), figure out what's causing the instability, Robison advises. "Review lab values, diagnoses, nursing and physician assessments, etc."

As for "other fractures" (J4d), which has a 180-day lookback, make sure staff note that a new fracture has been coded. Look closely for a pattern of fractures that may indicate osteoporosis, rough handling or abuse, Robison advises.

• Section M. Look at abrasions, bruises, burns and skin tears, which the MDS team should code in this section, Robison says. Skin tears do occur in someone with fragile skin, she adds. But if skin tears suddenly pop up on an assessment -- or if there's an erratic pattern where they are coded on one assessment but not others -- take a closer look.

"It could be a coding accuracy issue or it could be due to abuse or rough handling." (See "Know Where, How To Code A Skin Tear On The MDS," on p. 22.)