MDS Alert

Find out if you're coding and addressing everything you should be.

Imagine a good plaintiff's attorney whipping out a resident's MDS, care plans, and medical record to show the jury how the facility's care team didn't attempt to prevent serious diabeticrelated outcomes.

You can avoid that kind of nightmare scenario and improve care by using the MDS as a risk management tool. The assessment can not only ensure you're providing the right services, but it can also help you home in on the big picture, including problems that could be caused by diabetes.

First of all, make sure you code in Section I1 that the resident has diabetes mellitus, and related complications, such as diabetic retinopathy. Also code a diabetic ulcer using a specific ICD-9-CM code in I3 (for details on how to do that, see the last issue of MDS Alert, available in the Online Subscription System).

Next: Take a close look at whether you assessed the resident for these following conditions coded on the MDS where applicable. Also make sure you have the documentation and care plan in place.

Residents with diabetes should receive a yearly neuropathy screen, advises Naushira Pandya, MD, CMD, who chaired the American Medical Directors Association diabetes mellitus clinical practice guidelines. If the person has peripheral neuropathy, he should have protective foot wear, daily foot inspections, and diabetic shoes, she adds.

"You can step up diabetic control through use of oral medication or insulin," advises Pandya.

• Abnormal labs (P9). This item does include abnormal glucose fingersticks, notes Jennifer Gross, RN, BSN, a healthcare specialist with PointRight Inc. in Lexington, Mass. "It's not a precise item" because you  code any abnormal lab, she adds. "But coding that item provides a part of the global picture." Also take a look at whether the care team is addressing abnormal labs for a person with diabetes, including glucose, lipids, and A1c.

• Depression and cognitive function. These conditions are more likely to occur in people with diabetes, Pandya relates.

• Foot care. "If a diabetic has foot callous(es), send the patient to a podiatrist for a good foot exam," advises Evonne Fillinger, RN, BSN,WCC, RAC-CT, clinical operations consultant with Boyer & Associates in Brookfield, Wis. "People with diabetes should have a foot exam frequently, and be seen regularly by a physician," she says.

• Syncope (J1m). If the person has a fainting spell(s) coded, has anyone investigated whether hypoglycemia could be the cause? Even if the team has addressed this problem, make sure it's care planned,  documented, and monitored.

• Falls (J4). "Falls could be related to hypoglycemia," says Gross. In addition, look to see if the person falls because he has an unsteady gait due to peripheral neuropathy. Perhaps the person has problems walking well because he can't feel where to put his feet, Gross points out.

• Pain (J2). Does the resident have pain due to peripheral neuropathy? If so, is he receiving medication specifically for neuropathic pain?

• Skin ulcers (Section M). Does the care plan address specific woundhealing issues related to the diabetes?

• Weight gain or weight loss or poor meal intake (Section K). These items should trigger review, advises Gross. Hopefully nursing has been monitoring the intake related to insulin administration, she says. If the person has been leaving 25 percent or more of his food, has someone taken a look at why the person isn't eating more of his diet? Are the portions too big or is the food not to the person's liking?

• Vision (Section D). The patient with diabetes needs a yearly eye exam, says Pandya. A careful visual assessment for Section D may pick up thefirst signs of diabetic retinopathy. Or observation of a resident's behavior may tell you something is wrong. In one case, a nurse noted that an elderly resident with diabetes kept rubbing his eyes and tilting his head as he watched a football game. She asked him what was wrong and he said that an image in part of the screen looked funny. The facility scheduled the resident for an immediate retinal exam, which expedited treatment for leaking retinal blood vessels.