MDS Alert

Here's how one facility shored up its MDS troops.

Does it really pay to make your frontline staff an integral part of your MDS process? Good Shepherd Nursing Home is counting the ways: better quality outcomes, more accurate payment, low staff turnover ... and eight consecutive deficiency-free surveys.
 
The facility attributes its stellar survey record to the fact that all of the care staff, including the CNAs, are very in tune with each resident's care needs. "The CNAs help collect MDS data and connect the information to the care plan," explains Tom Lohuis, an RN and operations director and administrator for the facility in Seymour, WI. "They also know how to use the MDS-generated quality indicators on the units and really buy into the MDS process," he adds.
 
Of course, all of that takes training and more training. But Lohuis believes the CNAs' participation in the MDS assessment and resident care helps them achieve a level of commitment and job satisfaction that money can't buy. To support that contention, he notes that the facility's turnover for CNAs is low - 17 percent - compared to 40 to 50 percent for the national average and 100 percent in some states. "And since we pay middle of the range, we believe our attrition rate has more to do with getting frontline staff invested in their jobs and providing recognition of their valuable contributions" than it has to do with money, Lohuis says.
 
Good Shepherd CNAs assess the residents in a way designed to supplement the data collected by the nurses and MDS staff. The frontline staff also collects extra information that verifies what the nurse has documented. The nursing assistants complete ADL reports, a Braden scale for pressure ulcer risk, behavior reports and a sleep assessment tool that the RN analyzes (including one for residents with dementia or aphasia). (See the "Behavior Assestment".) "If the resident is incontinent, they do a bladder record to see if the bladder program is still working - and, if not, they can help us tweak it and make it more effective," says Lohuis
 
The CNAs also help shape the care plan by sharing what they view as no longer valid on the plan and/or effective new interventions they've found. Their participation and input in the care planning process not only improves and individualizes care, it serves as a form of ongoing education. "For example, when they do the Braden scale - which is not typically done by CNAs - they learn the risks for skin breakdown, so they can be more alert to changes in the resident's risk level and report that to the nursing staff immediately," Lohuis explains.
 
To give CNAs more autonomy, Good Shepherd banished the traditional reporting hierarchy so that CNAs who notice a decline in the resident's function can go directly to the rehab therapist with their concerns.

Hone in on These Critical MDS Sections
 
The CNAs are required to focus on some MDS sections more than others, including activities of daily living in Section G. "That's important," Lohuis says, "because the nurse may not be aware of how a resident's functioning declines as the day progresses." CNAs are also expected to know the resident's nutritional intake and fall record.
 
CNAs also play an important role in observing residents' moods and behaviors. "We find that staff get used to the way the resident behaves or the resident's moods, so they stop reporting it," Lohuis tells Eli.  "And that means depression or behaviors may not be coded on the MDS, which can affect payment - or make it appear that the resident has improved when that's not the case," he says. Thus, the administrative staff makes an ongoing effort to remind CNAs to report what they actually observe so the interdisciplinary team knows when to step up or change psychosocial interventions.

Stay on Top of Significant Change Assessments
 
Frontline staff's involvement in the MDS also helps the facility avoid missing significant change in status assessments. CNAs, as well as dietary and therapy aides, know to report any change in the resident's condition at any time. Lohuis estimates that the facility does at least one change in condition MDS weekly, which usually results in better Medicare payment.
 
Staying on top of significant changes also keeps care in "real time" to meet the resident's emerging needs, which is the focus of the whole MDS process.