MDS Alert

Take advantage of the wiggle room for factors beyond the facility's control.

MDS coding is risky business when you don't capture MDS items that risk-adjust your quality indicator/measures.

Example: Cognitively impaired residents receiving antipsychotics will flag as high risk for receiving the meds if they have cognitive impairment (defined as any impairment in daily decision-making where B4 > 0) and short-term memory problems (B2a =1) and behavioral problems. The latter include any one of three behavioral indicators or symptoms in E4: verbal abuse, physical abuse or socially inappropriate/ disruptive behavior.

The problem: Socially inappropriate/disruptive behavioral symptoms can be more difficult to capture than overt physical aggression, notes Maureen Woods, RN, the MDS coordinator for the Baldomero Lopez State Veterans' Nursing Home in Land O' Lakes, FL. "The CNAs will say the resident isn't socially inappropriate, but someone who sings all night can fall into that category," says Woods. "So you have to make sure that the CNAs know how to define socially inappropriate based on the RAI manual definition."

Review the definition at www.cms.hhs.gov/quality/mds20/raich3.pdf (page 3-66).

Another example: Cognitive impairment (B4 > 0 and B2a =1) or psychotic disorders (schizophrenia or manic depression checked in Section I1 or psychotic disorders coded in I3) also place a resident in the high-risk category for prevalence of behavior symptoms affecting others.

Check Risk Status for Pressure Ulcers

Undercoding bed mobility or transfer ADLs can move a chronic-care resident with a pressure ulcer into a low-risk category--a sentinel event in surveyors' books. Residents with bed mobility scores at G1aA of 3, 4 or 8 or transfer scores at G1bA of 3, 4 or 8 should go in the high-risk category for developing a pressure ulcer. 

Quality assurance tip: When a resident flags on the pressure ulcer QI/measure, the interdisciplinary team at Little Flower Manor pulls his original skin assessment, which the nurses perform before the facility does the MDS. The staff then compares the risk assessment to portable ultrasounds of the resident's skin that identify fluid under the skin signaling pressure-induced damage and risk of skin breakdown, reports Nancy DeFranco, RCN, BSN, CNDLTC, MSHA, director of nursing for the Wilkes- Barre, PA facility. "We also look to see that we have care planned to meet all of the identified risks" and have coded the interventions on the MDS, she says.

Revisit End-Stage Disease, Hospice

Residents with end-stage disease checked at J5c (which requires physician certification) or receiving hospice services coded at P1ao will be excluded from the following QIs/QMs:

• 9.1 Residents who need more help with their ADLs;

• 9.3 Residents whose ability to move in and around in the room got worse; and

• 13.1 Short-stay residents with delirium.

Hospice services coded at P1ao also exclude a resident from flagging on the QI/QM identifying residents who lose too much weight.

Remember: You can't code your facility's palliative care program at P1ao unless it meets the RAI manual definition of a hospice, according to a recent RAI manual clarification. A resident "is identified as being in a hospice program for terminally ill persons where an array of services is necessary for the palliation and management of terminal illness and related conditions," states the manual.

"The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider."