MDS Alert

Here's how to create another layer of safety to catch cracks in the system before it's too late.

Doing the MDS provides an ideal time to perform QA checks that can help prevent resident harm, not to mention staff and facility liability.

A real-life example: Attorney Jennifer Gimler Brady knows of a situation in which an LPN failed to notify the physician about a diabetic patient's elevated blood glucose readings. The LPN obtained and recorded the intermittently high blood glucose readings over a number of weeks, giving the oral diabetic medication as ordered. The facility discovered the omission and treated it as a disciplinary and counseling matter. Once notified, the physician tweaked the resident's medication, which alleviated the high blood sugars, says Brady, with Potter Anderson & Corroon LLP in Wilmington, Del.

Some time later, regulators discovered the error during an audit and referred the matter to the Medicaid fraud control unit. And when the investigators talked to the director of nursing, their focus began to shift to --"Why didn't you pick up on this?"Brady says.

In another case reviewed by a legal nurse consultant, an elderly dialysis patient's potassium values had been trending high for some time before he suffered a cardiac arrest. The family's attorney in the case claimed the man's heart stopped due to hyperkalemia.

Lessons learned: When coding the MDS, look for shortfalls in documentation and care related to lab results and other clinical issues.

For example, to code abnormal labs, you need clinical documentation to support what you code. In looking for that documentation, audit the clinical record to ensure that staff notified the physician timely about abnormal lab values, advises Nancy Augustine, RN, MSN, a consultant with PointRight Inc. in Lexington, Mass.

The record should also show follow-up that meets the industry standard of practice, such as repeat lab orders in some cases, physician documentation and professional nurse monitoring of patients with lab results, Augustine adds.

Another safety check: The consultant pharmacist plays a major role in making recommendations for medication-related lab tests, Augustine notes. So make sure the documentation shows the physician received notification of these recommendations in a timely way.

Get the QA team on the case: If the facility has any hint of problems in terms of reporting or managing lab results, it could do a focused QA activity looking at that issue, suggests Marilyn Mines, RN, RAC-CT, BC, manager of clinical services for FR&R Healthcare Consulting in Deerfield, Ill. For example, as part of a quarterly or monthly review, the MDS nurse could give the QA committee a list of all residents with an abnormal lab coded at P9, she advises. The QA committee could also review lab results for patients who are getting certain types of routine testing, such as INRs for warfarin, Mines suggests. Or identify which people are taking certain medications to see if they are receiving routine lab testing or if they should be based on their symptoms, she adds.