MDS Alert

Licensed nurse's expertise + CNA input = ADL accuracy.

Licensed nurses and CNAs bring different pieces of the ADL equation to the assessment table -- and if either of these key players is missing, don't count on winning fair payment for the facility.

Be proactive: Develop systems in which the MDS nurse or licensed nursing staff collaborates with CNAs to determine each resident's actual ADL status. That approach will help you avoid a chronic case of ADL over- or undercoding that can lead to payment recoupments -- or short change your bottom line.

Consultant Julie Thurn-Favilla, RN, MSN, tends to see ADL overcoding when just the nurse does the ADL assessment and documentation without input from CNAs. For example, the nurse may take a "snapshot assessment" of a resident who is very dependent on staff for late-loss ADLs and code the person as a "4" for total dependence. But the resident actually performs some subtasks of an ADL, which means he isn't totally dependent, says Thurn-Favilla, with LarsonAllen in Milwaukee.

Conversely, if the nurse relies solely on the CNAs' documentation, the ADLs tend to be undercoded, in Thurn-Favilla's experience. "That's because the nursing assistants are so used to what they do for the resident on a daily basis, they may not realize, for example, that lifting the resident's leg each shift to help him reposition in bed counts as weight-bearing support for bed mobility."

Real-world practice: To ensure ADL documentation is accurate, MDS nurse Cindy Mahan compares her assessment of the resident to the information on the CNAs' ADL flow sheets each day. She then addresses any ADL coding that doesn't jibe with her own observations.

Example: If the CNAs have left bed mobility blank for a particular resident -- and Mahan sees the resident is sleeping in a recliner -- she will ask the CNAs if they had to help the person position or pull him up in the recliner. "The RAI manual says a recliner in which the person sleeps counts in coding bed mobility," explains Mahan, who is the MDS coordinator for Woodbriar of Wilmington in Wilmington, DE.

Or if Mahan knows a resident has had a total hip replacement and the ADL flow sheet doesn't show a certain amount of assistance, she will ask the CNAs how much the resident has been doing and how much support they have provided.

ADL training tip: To help CNAs understand the essential difference between supervision, limited and extensive assistance for determining a resident's ADL self-performance, Bet Ellis, RN, teaches them that supervision involves using the eyes and ears to assist the person.

"Limited assistance means the resident did more than the staff," she says. And extensive assistance occurs when "the staff did more than the resident," adds Ellis, with LarsonAllen in Charlotte, NC.