MDS Alert

Use all of your senses to determine a resident's hearing ability.

Every facility has to accommodate residents' hearing loss, and most also work with hearing aids. Though the Resident Assessment Instrument (RAI) MDS does not delve too much into hearing loss, knowing how to best communicate with affected residents is key to happiness and contentment all around. Plus, hearing aids are wildly expensive - and resident families are never pleased when they disappear on a facility's watch.

Surveyors are looking out to make sure facilities are doing their best with hearing loss. Hearing aids appear in several citations in the most recent version of the full text of Statements of Deficiencies (https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/fsqrs.html). Review of Appendix PP and the guidance provided is helpful when looking over your facility's policies.

Assess these particulars

The 2018 draft of MDS 3.0 doesn't ask much about hearing loss or physical accommodations like hearing aids or other tools, but the RAI Manual is a bit more helpful. The RAI Manual stresses that hearing can have a major impact on a resident's well-being, and hearing loss (especially undiagnosed or not properly accommodated) can be a major contributor to social isolation.

Be careful: Some residents with hearing loss are inaccurately assessed or misdiagnosed as having cognitive impairments or dementia.

When assessing hearing capacity, make sure the resident is using any devices she normally uses, like a hearing aid. Do your best to make sure the interview and assessment take place in a quiet area, with as little background noise as possible.

Note: Residents with hearing loss may choose an accommodation that isn't as conventional as a hearing aid, the RAI Manual says on page B-3. Whatever the device - microphone and headphones or an amplifier, for example - make sure it's working correctly before beginning.

You may need to adjust your usual speaking volume or enunciation to make sure the resident can understand you, but be wary of overcompensating for hearing loss (or spoken English being a resident's first language) and unintentionally causing offense. (See "Person-Centered Care: Use These Words, Avoid Certain Tones" in MDS Alert Volume 15 Number 12 for more information.)

When interviewing the resident, make sure to ask about her hearing in different situations and activities. Though she may hear fine in the quietness of her room, it may be hard for her to hear a companion's quip during a loud meal in the dining area. Ask her about whether she can hear staff during conversations, and whether she can hear the television and telephone.

Use your own observations, too, to better the accuracy of your assessment before you code the resident's hearing in the MDS. See how the resident interacts with others in different situations throughout the day. And, as always, review the medical record. Check in with other people who know the resident, too, especially the family - to have a better idea of that resident's baseline hearing, particularly if the resident is new to your facility - and other team members who interact with the resident every day, including those who deliver direct care, as well as speech therapists and hearing specialists.

Top tip: Residents who experience cognitive impairment may need special accommodation for the interview and assessment. "The resident can be observed in their normal environment. Does he or she respond (e.g., turn his or her head) when a noise is made at a normal level? Does the resident seem to respond only to specific noise in a quiet environment? Assess whether the resident responds only to loud noise or do they not respond at all," says the RAI Manual.

Coding hearing and hearing aid

The lookback period for item B0200 (Hearing) is seven days. Code B0200 with the following values, per the RAI Manual, page B-3.

• "Code 0, adequate: No difficulty in normal conversation, social interaction, or listening to TV. The resident hears all normal conversational speech and telephone conversation and announcements in group activities.
• "Code 1, minimal difficulty: Difficulty in some environments (e.g., when a person speaks softly or the setting is noisy). The resident hears speech at conversational levels but has difficulty hearing when not in quiet listening conditions or when not in one-on- one situations. The resident's hearing is adequate after environmental adjustments are made, such as reducing background noise by moving to a quiet room or by lowering the volume on television or radio.
• "Code 2, moderate difficulty: Speaker has to increase volume and speak distinctly. Although hearing-deficient, the resident compensates when the speaker adjusts tonal quality and speaks distinctly; or the resident can hear only when the speaker's face is clearly visible.
• "Code 3, highly impaired: Absence of useful hearing. The resident hears only some sounds and frequently fails to respond even when the speaker adjusts tonal quality, speaks distinctly, or is positioned face-to-face. There is no comprehension of conversational speech, even when the speaker makes maximum adjustments."

The lookback period for item B0300 (Hearing Aid) is also seven days. Follow these instructions, per the RAI Manual.

• "Code 0, no: if the resident did not use a hearing aid (or other hearing appliance) for the 7-day hearing assessment coded in B0200, Hearing.
• "Code 1, yes: if the resident did use a hearing aid (or other hearing appliance) for the hearing assessment coded in B0200, Hearing."