MDS Alert

Did you know Section O packs this wealth of info?

Take a close look at Section O, and you won't be blindsided by negative medication-related and psychosocial outcomes.

Start with O1 (number of medications). If a resident triggers on the QI for taking nine or more medications--and you've counted the number of meds at O1 accurately--evaluate the appropriateness of his medications, advises Carla Saxton, PharmD, with the American Society for Consultant Pharmacists. "Perhaps the prescribing clinician can eliminate or reduce some of the medications--or maybe not," she says. "The consulting pharmacist and attending physician can help the facility make that determination," she adds.

Preempt problems at admission: "An experienced geriatrician can help identify medications that may be inappropriate for the elderly patient admitted to the nursing home from the hospital or community," says Daniel Haimowitz, MD, CMD, in Levittown, PA. Proton pump inhibitors and old-time medications, such as Elavil and Darvocet, raise red flags for him, as examples. "Sometimes people end up on the proton pump inhibitors and you never know why," he says. Any drug on the Beer's list requires review for a cost-benefit analysis," Haimowitz says.

Correlate coding at O2 (resident currently taking new medications initiated in the last 90 days) to the onset of unexplained symptoms or negative outcomes, including changes in mental status, weight or appetite changes, gastrointestinal problems, such as diarrhea or constipation, abnormal labs, incontinence--or falls, as key examples.

Crosscheck O4c, Depression Dx, and E1

Anytime you code an antidepressant at O4c, review a resident's medical record for a diagnosis of depression, including the proper coding of that diagnosis in section I of the MDS, advises Ellen Mullin, an MDS consultant and former surveyor in Montgomery, AL. "In the absence of a depression diagnosis, ask the physician to document the clinical rationale for prescribing an antidepressant at least annually, if not every six months," Mullin counsels. The documentation should include an analysis of the risks and benefits of the antidepressant, she adds.

If the resident is taking an antidepressant, look closely at E1 (indicators of depression, anxiety/sad mood) to see if these are decreasing in number within two to three weeks after the resident starts the medication. If not--or if the items in E1 are increasing in number or severity--check with the prescribing clinician to re-evaluate the resident's medication and dosage, Mullin suggests. Also revisit the person's care plan to identify additional psychosocial interventions to address the depression.

Survey tip: Be prepared to show surveyors non-pharmacological care plan approaches for residents who trigger on the QI for depression without antidepressant therapy. Examples include counseling, support groups, light therapy and aerobic exercise.

Document when the care plan team refers a resident with indicators of depression/anxiety/sad mood in E1 for further mental health evaluation and care. For example, Schervier Nursing Care Center refers a resident on its palliative care program to a psychiatrist for more in-depth assessment if the resident shows indicators of sad mood. The psychiatrist helps to determine if the person has a true clinical depression or could benefit from an antidepressant, says Joseph Scarpa, MD, medical director for the facility in Riverdale, NY. (For details about how the facility uses the MDS and other assessment tools in individualizing palliative care, see the December 2005 MDS Alert.)

Care Plan Residents With Behaviors, Psychosis

Correlate coding antipsychotic medications in Section O4a with the following MDS sections or items:

• Behavioral symptoms in E4.

• Psychiatric conditions checked in Section I1 or ICD-9-CM diagnoses recorded in I3).

• Psychotic symptoms in Section J (delusions and/or hallucinations).

• Unsteady gait and/or falls in Section J.

By performing the crosscheck, you can pick up a number of areas for care plan review, including:

Residents whose behavioral or psychotic symptoms (i.e., hallucinations) may warrant evaluation for treatment if you didn't code an antipsychotic in Section O4a. Upon closer inspection, you may find the resident is actually receiving an anticonvulsant as treatment for behavioral symptoms or a psychiatric condition. (Don't code an anticonvulsant in O4a even when the physician prescribes it to treat behavioral symptoms or psychiatric conditions.)
 
Residents who aren't improving on an antipsychotic medication. This may mean they need need a different medication or a higher dosage of their current medication.

Residents on antipsychotic medications who no longer have behavioral or psychotic symptoms coded on the MDS. If the resident has been symptom free for some time, for example, the interdisciplinary team can evaluate whether he may be a candidate for a trial dosage reduction or a goal of going off the medication all together.

Residents taking antipsychotics who have unsteady gait or who are falling. Some antipsychotics induce or aggravate motor and gait problems that can lead to falls. Clozapine and quetiapine carry the lowest incidence of Parkinson's-induced symptoms, says Joseph Friedman, a neurologist in Pawtucket, RI. Of the two, clozapine is the least likely to worsen gait or motor problems. But you have to monitor residents taking clozapine for agranulocytosis weekly for six months and then every other week, he notes.

"To ensure a high quality of care in treating residents with psychosis and behavioral issues impacting functional status, look at each resident taking a psychotropic medication," says Judy Wilhide, RN, RAI manager for Virginia. "Look at the resident's diagnoses--and the indications, medical necessity and risk-benefits for the medication," she adds. "Also look at how the staff monitor the resident for adverse drug reactions and the care plan goals for the medication." Document your ongoing analysis in that regard.