MDS Alert
Certain MDS Items Flag Residents With Higher Acuity
Let your documentation spell out your assessment, care.
If your preadmission or admission assessment reveals a patient has many of the following MDS items, make sure the SNF can meet his needs.
And document your assessment of the resident's condition and interventions to support that the facility could adequately care for the person, advises Marilyn Mines, RN, RAC, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL.
Here's a rundown of MDS items that you might see for a higher acuity resident.
• B5. Delirium.
• J1. Unstable conditions, such as fever, respiratory distress, fluid imbalance.
• J2. Moderate to severe pain.
• J4. Falls and injuries.
• J5a and J5b. J5 a identifies a resident with conditions that are making their ADLs, cognition, mood or behavior unstable. J5b records a resident who has had a flare-up of an existing chronic condition.
• Section I. Respiratory infection, dehydration, pneumonia, urinary tract infection, wound infection and other acute conditions
• K5a. IV fluids
• Services recorded in P1aa-P1ar, such as IV medications and oxygen therapy used to treat acute or emergent conditions.
• P1ad. Intake/output
• P1ae. Monitoring acute medical condition
• P7 and P8. Frequent physician visits and/or order changes.
• P6. Emergency department use.
• Abnormal laboratory findings (P9), such as electrolyte imbalances, unstable blood glucose in a diabetic or fluctuating INRs for a patient taking warfarin.
• Significant change in status assessment.
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