MDS Alert

7 ways managers can stay on top of their game by using this invaluable tool.

If you think of the MDS as a navigational system, the DON who doesn't understand how to use the instrument to steer clear of a survey or fiscal wreck may end up like the captain of the Titanic.

Here's what the experts suggest DONs should know - and do - with the MDS as a payment, quality of care, survey and operational tool: 

1. Determine if the MDS actually reflects residents' conditions and if the MDS sections/items are consistent. "The  DON should know the definitions for the various items and the scoring so he or she can audit the charts and MDS to see if they match and are correct," says Lynn Gerard, RN, DON for Guardian Angels Care Center in Elk River, MN. "That's a survey issue, as the facility can be cited for inconsistencies and inaccuracies in the MDS and assessment process," she cautions.

2. Make sure the hospital services are captured on the MDS. "The DON should make sure the person doing the preadmission screening knows the procedures used by the hospital to record care," says Gerard. "Oftentimes the hospital will tell you things weren't done but you know, based on the resident's diagnosis, that the resident most likely did have an IV or got a bolus of fluid in the emergency room or other treatments that can bump a resident up to SE3 on the five-day MDS," Gerard advises. 

For example, the nurses on the hospital floor may have no idea the patient got a 500-cc rescue bolus in the ER because he came in with acute confusion and the staff suspected he had dehydration. "But then the person turned out to have some other problem causing mental status changes, and he kept removing his IV, so the ER staff discontinued it after 24 hours of observation prior to inpatient admission," Gerard says.

"A GI bleed is another one where you may strongly suspect the person may have had a transfusion in the ER that's not recorded in the hospital discharge summary or the floor nurses weren't aware of it," says Gerard.

3. Use the MDS to benchmark and look for clinical programs that aren't anteing up. For example, if you know the national average for clinical depression in long-term care facilities is 50 percent, and your QI is at the 25 to 30 percentile, there is a good chance the MDS doesn't reflect some residents' true mood status, cautions Jane Belt, RN, MSN, a consultant with Plante & Moran Swartz Group in Dublin, OH. "And if you're not assessing it, you can't developing a plan to address it," she adds.

"If residents fall, it could be due to weakness caused by weight loss, or perhaps the resident is depressed and focused more on his distress than his safety," Belt notes.

Or say you have a toileting program but see a lot of patients checked on the MDS as being incontinent most of the time. How do you explain that discrepancy? Is it an accuracy issue? Is the toileting program not individualized or based on an accurate assessment? Are staff really carrying out the toileting program?

"You have to drill down to figure out the reason for the QI that you cannot explain," says Belt, who has seen residents on restorative programs that have nothing to do with the problem recorded on the MDS.

For example, Belt has found instances where the resident has significant weight loss, but he is on a dressing and grooming program rather than an eating/dining program.

4. Use available MDS reports to stay on top of the MDS and QI process. Top on the list: the final validation report to see errors, including fatal errors that must be corrected for the MDS to be accepted by the state database so the facility can bill for the days covered by that MDS.

To tap the wealth of online MDS reports available, review the Long-Term Care Facility User's Manual, advises Pam Manion, RN, MSN, corporate nurse with Delmar Gardens Enterprises in Maryland Heights, MO.

Chapter four of the manual explains the various scheduled reports and CASPER online reports and how to access them (www.qtso.com/guides/mds/ltc/section4.pdf). And there's an entire appendix on CASPER reports at www.qtso.com/guides/mds/ltc/append_b.pdf.

Troubleshooting tip: If you're having browser problems that prevent you from accessing the online CASPER reports - or if you experience other problems - call the Quality Improvement Evaluation System (QIES) technical support office help desk at 1-888-477-7876.

5. Audit key sections that drive payment. For example, you definitely want to target Sections G (physical functioning), P (special treatments and procedures), E (mood and behavior) and B (cognitive patterns), at a minimum, Belt says (for the how-to details, see the October 2004 MDS Alert).

6. Know the algorithm to determine the MDS-derived RUG score for each resident. Without that know-how, the DON won't know if the MDS coordinator or Medicare team has selected the correct assessment reference date (ARD) to capture the highest intensity of services/acuity for reimbursement, cautions Gerard. She recommends DONs have the RUGs algorithm readily accessible and, once they learn it, develop a checklist that's faster and in a format that works best for them.

For a copy of the RUGs algorithm, go to www.cms.hhs.gov/quality/mds20/rai1202ch6.pdf.

7. Know the time and resources required to do the MDS well. "One of the biggest problems MDS nurses face is a DON who doesn't have enough familiarity with the MDS process to have realistic expectations," says Holly Sox, RN, RAC-C, MDS coordinator for J. F. Hawkins Nursing Home in Newberry, SC.

For example, Sox worked for one DON who expected her as the MDS coordinator to keep up with all new physician orders and MDSs for an 118-bed facility.

"By the same token, a DON who doesn't understand the process can be taken advantage of by people who want to work the system and not pull a full-time load," Sox cautions.

Editor's Note: For more information on how to determine a fair workload for the MDS nurse by using online MDS reports, time studies and benchmarking of times required to complete various types of MDSs, see the June 2004 issue of MDS Alert.