MDS Alert

Beware: This ADL can get tricky -- here's what to look for.

Not only does helping residents with their toileting require a lot of nurse staffing time, but coding the ADL accurately requires specific know-how.

For one, you have to know how the RAI user's manual defines toileting as an ADL, which includes how the resident:

• Uses the toilet room, commode, bedpan or urinal;

• Transfers on/off the toilet;

• Cleanses, changes pad, manages his ostomy or catheter, and adjusts clothes.

If the patient needs help with any of the steps involved in toileting, as described above, he is not independent in toileting. "Toileting also includes changing a brief," says Christine Twombly, RN, chief clinical consultant with Reingruber & Company in St. Petersburg, FL.

CNAs sometimes don't understand that holding the urinal for a man who can't do that constitutes weight-bearing assistance for toileting, says Evone Fillinger, RN, BSN, WCC, RAC-CT, a consultant with Boyer and Associates in Brookfield, WI. (Code extensive assistance if staff provide three or more instances of weight-bearing assistance over the lookback -- see p. 79 to review the definitions for ADL self-performance.)

Undercoding support provided for toileting can easily occur if the MDS nurse fails to capture a single instance of a two-person assist, which may have happened on the night shift, for example. This tends to happen with both transfer and toileting ADLs, comments Nathan Lake, RN, BSN, MSHA, an MDS and long-term care expert in Seattle.

Test yourself: How would you code a resident who routinely required two staff members to pull him up in bed before placing him on the bedpan over the lookback?

Pulling the resident up in the bed would count as bed mobility while placing him on the bedpan would be toilet use, says Marilyn Mines, RN, RAC-C, BC, manager of clinical services for FR&R Healthcare Consulting in Deerfield, IL. "The toilet use coding would be 3/3 [extensive assistance and a two-person assist]." Or it "would be 4/3 [total dependence and a two-person assist] if the resident does not help at all in any part of the toilet use definitions" over the entire lookback, she says.

Remember: If the resident does absolutely nothing for toileting -- and the caregiver does every step each and every time during the lookback -- code that as a 4 for total dependence, says Twombly. "If the person did the slightest thing even once during the lookback, code that as a 3."