MDS Alert

Save time, prevent payment recoupments and improve outcomes.

What do restorative services, toileting and continence have in common? Plenty if a resident is receiving restorative nursing interventions that should affect how well he performs his toileting ADL (Section G1) and continence status (Section H).

In fact, coordinating data collection and analysis for all three will improve MDS accuracy, supportive documentation, care planning and outcomes. It also pares down the number of forms that can cause the team to miss the big picture.

Consolidating data collection for restorative, toileting and continence doesn't mean you have to reinvent the wheel. Instead, you can adapt the paper forms already in use to capture more information.

Example: Consultant Jennifer Gross, RN, RAC-CT, BSN, notes that a lot of restorative nursing forms allow you to see what restorative services a resident received, his progress and how the nurse monitored the resident's program. Using such a form, you could add a place for narrative notes to document how the restorative aids are working with the resident on toileting or components of toileting, such as transfers or hygiene and redressing that's part of the toileting ADL, suggests Gross, with PointRight Inc. in Lexington, MA (formerly LTCQ Inc.).

Help for Section H: On the restorative form, the restorative nurse or aids could also note whether the resident was wet or dry at the time of scheduled toileting or bladder retraining. "This would provide a data point to look at the resident's continence status over the MDS lookback," Gross says. You can also use that as support documentation for scheduled toileting or bladder retraining in Section H if the criteria are met for those programs, Gross adds.

Tip: Scheduled toileting involves developing a plan by which the resident is toileted according to an individualized schedule based on assessment of the resident's normal routine and incontinence patterns, says Gross (for a recent Centers for Medicare & Medicaid Services' tip sheet on this issue, go to http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/MDS20ToiletingTipSheet.pdf). The scheduled toileting plan should be well documented and evaluated and revised as needed, Gross counsels. "Bladder retraining goes a step further in having the resident consciously delay voiding until a scheduled time in order to restore bladder control," adds Gross.

Remember: Either a scheduled toileting plan at H3a or bladder retraining at H3b counts as one restorative nursing activity (but not two if you provide and code both).

Another idea: Devise ADL flow sheets to incorporate continence monitoring. That way you'll have one form to provide data for Section G1 and Section H. Gross advises using such a form for an entire month to coincide with the MDS assessment or on an ongoing basis. The lookback for coding continence in Section H is 14 days, whereas the ADL lookback is seven days.

Another option is to take a look at what your computerized systems allow you to do in terms of data collection and analysis. For example, Extendicare Health Services in Milwaukee, which uses the CareTracker, is building a prompt into the electronic data collection process that will allow the CNAs to record the amount of toileting assistance they provided for a scheduled toileting plan, reports Rita Roedel, RN, national director of clinical reimbursement for the long-term care chain in Milwaukee.

Also: Most electronic systems for MDS and documentation now have some point-of-care data collection that allows you to define what questions to ask and how to answer them, observes Nathan Lake, RN, BSN, MSHA. For example, "the restorative aid could not only record the minutes of restorative services provided but rank the resident on a scale as to how well he did that day," says Lake, director of clinical design for American HealthTech based in Jackson, MS. The CNAs can also use the hand-held PDA device to record that a resident was incontinent at a certain time. "Then the data can be mined and analyzed," Lake says.

Review information about a resident's restorative services, toileting ADL scores and continence in tandem to identify potential problems and adjust the care plan, if needed. For example, if the person is receiving restorative interventions to improve his toileting ability, how is he performing that ADL over all shifts?

Red flag: Take a closer look at a resident who performs better with toileting on the day shift but consistently requires more help on the evening or night shift. Perhaps staff is doing more for the resident on those shifts than he actually requires, thereby promoting dependence, Gross says. Staff should support the resident's toileting performance on all shifts -- not just when he's receiving the restorative intervention on the day shift, she adds. Or perhaps the resident's toileting ability has improved except at night when he's tired.

Another question: If the resident's toileting ability is improving or he's participating in a scheduled toileting plan or bladder retraining, how has that affected his continence status?

Pivotal point: To be on a restorative program, the resident should be at least maintaining his function, Gross says. If he isn't progressing or maintaining function related to the restorative goals, the restorative team should evaluate the person and perhaps change the goals, interventions -- or determine if he's an appropriate candidate for a restorative program, she adds.

"The person might have a medical condition that needs addressing," says Gross.