MDS Alert

Overuse has raised a flag for CMS, says agency official.

A CMS official recently gave nursing facilities a heads up about a potential coding shortfall that you might want to make sure isn't occurring on your watch.

In finishing up an initial analysis of MDS 3.0 data, the agency found that "up to 40 percent of assessments" have dashes, including on pain and pressure ulcer items, relayed the agency's Thomas Dudley, during the May 2011 SNF/LTC Open Door Forum.

"At initial glance, this is concerning since the missing data will have implications for quality measurement rates that are reported for facilities," he cautioned. When pressed by an ODF caller for details about the dashes, Dudley did say that the dashes were seen "most notably on the discharge assessment," but also on all of the assessments.

In the near future, "CMS will be providing more detailed guidance about when use of dashes is appropriate," Dudley relayed. Until then, however, CMS is stressing that providers should fully complete MDS assessments with the information they have at the time of the assessment, he said.

Dudley went on to note that CMS appreciates providers' assistance with this, noting how they are still in a transitional period in terms of getting used to the MDS 3.0. But it has "thrown a flag up at us when we saw such a large number" of dashes. He said CMS will be "getting feedback from the various different people in the SNF world to get a better understanding on our part."

It is possible to do skin assessments for residents with unanticipated discharges -- "unless the resident was only in the building for a few minutes or hours," observes Judy Wilhide Brandt, RN, RAC-MT, C-NE, of Judy Wilhide MDS Consulting, Inc. in Virginia Beach, Va. The pressure ulcer 'head to toe' [assessment] should be immediate," so Brandt finds "leaving that one blank extremely concerning."

"If the entire Section M is 'dashed' and the resident was there more than a day (and if I were director of nursing, I'd say more than an hour) then we should know what their skin looks like," adds Brandt.

Consultant Marie Saunders, RN, BSN , BC, in fact, advises all her clients to do skin examinations within the first hour of admission to identify whether a pressure ulcer was present at admission/readmission. "If the resident has been in the facility for more than two hours and you haven't done the examination, it's very difficult to prove that a pressure ulcer didn't develop in your facility," adds Saunders, principal of Saunders Associates in Appleton, Wis.

Brandt notes there are instances where the physician may have to come to the facility to help identify the etiology of a wound. In such cases, however, "the MD needs to come right away" so the facility knows how to treat the wound.

What about doing pain assessments for unplanned discharges? If the staff didn't do the pain interview due to an emergent discharge -- "or if the resident is 'rarely or never understood' and you are skipping [the interview] all together"-- you could do the staff assessment for pain, advises Rena Shephard, MHA, RN, RAC-MT, CNE, CEO and president of RRS Healthcare Consulting in San Diego. That assessment involves observation of nonverbal indicators and vocal complaints, Shephard points out (see the pain items below). And "certainly the staff has been observing the resident for the time he was there." Hopefully, the medical record would include the observations during the lookback that you can use to complete the staff observation for pain, says Shephard. "It would be the standard where you observe something and document it at that time," she says.

"But if the resident were discharged emergently and the nurse is trying to complete the discharge assessment," it would be appropriate for the nurse to ask staff if they observed the staff assessment pain items in the lookback period, Shephard adds. If that information wasn't documented in the chart, "the assessor can write a brief note in the chart, identifying the source of the information and date and time she/he received it." You want to include the time and date so it's clear the information applies to the lookback period, she adds. "This isn't any different for emergent discharges."

Facility managers can be proactive in evaluating use of dashes, Brandt notes. "If I'm the administrator," she says, "I'm meeting with my MDS coordinators weekly as this point and listening to what they are saying. I am having  routine targeted and random audits of all sections by all contributors [including] witnessed interviews. I ask my team: 'Are you dashing a lot of sections? Why?' and Iverify their answers with audits."

Brandt's "second piece of advice? Don't jump the gun and go into crisis mode until we get hard data" about the dashes from CMS, she says. "If your audits show there isn't a problem, just sit tight, and stay the course."