MDS Alert

Here's the surprising conclusion a QA team reached about a fall-related injury.

To ferret out whether a fall reflects a systemic issue - or a one-time bump in your quality indicator  - look to these data sources.

1. Online Survey and Certification Reporting System. The OSCAR 3 report summarizes a facility's regulatory compliance history, notes Laura Ferrara, RN, MSN, who reported on her QA team's analysis of a resident being treated for pneumonia who fell getting out of bed and lacerated her head. Ferrara presented the case at the most recent American Health Care Association annual conference in Miami (see previous page for details).

The OSCAR 3 report showed the facility had received a number of deficiencies over the past few years, including F323 and F324 tags for accident prevention.

The OSCAR 4 report comparing the facility population characteristics with state, CMS region, and national averages revealed that the facility's percentage of residents coded on the MDS as occasionally or frequently incontinent equaled the state average. Yet the report also showed that no residents were on a bladder training or toileting program. "And that's a red flag for an MDS inaccuracy problem," said Ferrara.

The OSCAR 4 reports also showed the facility had a relatively independent population coded on the MDS. So how could the facility have an independent population with such a relatively high rate of incontinence and a history of F323 and F324 tags?

2. Cost Reports. A facility's Medicare cost reports show the annual aggregate of all RUG categories, including the general ADL index. The ADL index jibed with the OSCAR 4 statistics, showing an independent resident population. But the RUGs also showed residents had a high incidence of depression and behaviors.

3. Minimum Data Set. The MDS also showed a high incidence of residents with impaired decision making (coded at B4) and behavioral symptoms (coded in Section E4). And residents with such problems may actually require more assistance with toileting and safe mobility than the facility's ADL scores overall reflected, Ferrara concludes.

The MDS also revealed a majority of moderately cognitively impaired residents who could have benefited from a toileting program. "The combination of incontinent residents with dementia and behaviors who weren't receiving needed assistance to go to the toilet creates a fall risk," Ferrara cautions.

For example, while 46 residents in the facility had a toileting plan, 29 did not, Ferrara reports. And 20 of that 29 had moderate cognitive impairment but could have succeeded with a toileting program. "Seventy-five residents were incontinent and 33 of them had suffered a fall. Twenty-nine of the 33 did not have a toileting plan," reports Ferrara. Yet in spite of all of the data suggesting a systemic issue with incontinence and falls, the facility's QIs for those problems weren't flagging above 75 percent.

The data analysis cast new light on the resident with dementia who fell trying to get out of bed unassisted. For example, the staff could have figured out the resident's toileting time at night to offer individualized assistance. And that intervention might have prevented the resident from getting up on her own and tumbling out of bed, Ferrara postulates.

Another omission: The resident had pneumonia diagnosed a week before her fall. "And even though the pneumonia may not have been enough of a change to warrant a Significant Change in Status Assessment (based on RAI manual definitions), the staff should have updated the care plan to provide more assistance and monitoring in the period after that acute illness," Ferrara suggests. "The resident also could have used extra ADL support during that time to prevent a further decline," she adds.

The bottom line: To reduce the facility's risk of falls overall, nursing staff needed to provide more restorative interventions to get residents on toileting plans and improve their ADL functioning, concludes Ferrara. "By providing restorative nursing and more appropriate ADL assistance, the facility could also improve its reimbursement," she adds.