MDS Alert

Hint:  Surveyors may be paying closer attention to coding at G7.

"It's elementary, dear Watson," as Sherlock Holmes is famous for saying. And you'd better make your ADL instructions elementary for cognitively impaired residents if you don't want surveyors doing some sleuthing to see if your facility is causing physical or psychosocial harm.

Know the definition: Task segmentation is a "way of breaking down a multi-step process in a manner that allows a person with a physical or cognitive impairment to succeed at the task," explains Steven Littlehale, MSN, RN, chief clinical officer for LTCQ Inc. in Lexington, MA.

The survey reality: Doing task segmentation coded at G7 is one task you don't want to omit with the new Psychosocial Outcome Severity Guide now in effect.

Why is that? The RAI manual guidelines "tie task segmentation to psychosocial issues," observes Jennifer Gross, RN, BSN, also with LTCQ. The manual discusses how residents can become anxious or dependent if they aren't meeting expectations to perform their own ADLs.

Yet "the resident would be able to be more independent if staff broke the task down one step at a time," Gross points out.

"Without helping residents with task segmentation, staff might foster dependency, which can cause the resident to become depressed."

Skip the Cookie-Cutter Approach

Saying you're providing task segmentation and coding it at G7 is one thing. But surveyors could call you on the carpet if they see you're using a "one size fits all" approach to providing the ADL assistance.

Forget the canned care plans: A task segmentation strategy that "works well for one resident may not work at all for another resident," Littlehale cautions. He notes that one resident might respond best to simple verbal commands to perform each ADL subtask. But another resident might flounder with verbal prompts because he requires more visual cues or other "controls in the environment" to perform a task, Littlehale adds.

Example of a nonverbal prompt: When assisting a resident who does better with visual cues, you may not say a word but hold out two pieces of clothing. This nonverbal strategy "focuses the resident on the task, yet still offers him a choice at which he can succeed," says Littlehale. It also "engages him in the process."

For another resident who can interpret simple verbal prompts, you might say, "Please pick up your cup" and let the person follow that instruction before giving him another one, Littlehale advises. Another resident may be at a level cognitively in which she can perform a few tasks rolled into a single request, such as "Please eat your sandwich."

Tap Into Dementia Residents' Strengths, Automatic Memory

Don't underestimate what a resident can do if you identify and play on the person's residual abilities.

Example: Say a resident is disoriented to person, place and time and completely dependent on staff for ADL care. "If you start an action for the resident," such as lifting his "cup-holding hand toward his mouth" or touching the person's arm and holding out a sweater sleeve, often he will pick up and finish the motion, explains Littlehale.

Completing that task may "seem insignificant to us," Littlehale adds, "but the resident may have a sense of mastery by finishing the task." For example, "what's more 'normal' than drinking from a cup?"

CNAs also "find it a lot easier to start someone in an activity and having the resident finish it than doing it completely," adds Littlehale.

Clinical tip: To encourage a cognitively impaired resident to wash his hands, hand him a warm washcloth with soap on it, which will stimulate him to use it, says Cissy Bloomfield, director of nursing at a facility in Jacksonville, IL.

Can the resident mirror the actions of others? In a study, Littlehale and his research cohorts identified residents with dementia who could copy or mirror someone. Then they'd place those people at the dining table with a CNA who would sit in "plain view of the residents. She would deliberately pick up a utensil and feed herself while maintaining an open and friendly nonverbal posture," Littlehale relays.

Like magic, each of the residents then picked up his or her utensils and followed the CNA's actions. What's more, previously, staff had been completely feeding many of these residents, Littlehale says.

Use Task Segmentation for People With Physical Disability

Task segmentation can also help residents with a physical disability that prevents them from performing an ADL "if staff don't break the task into simpler steps," says Gross.

Common example: A patient with congestive heart failure becomes tired and short of breath if he tries to do an entire task without stopping frequently to rest. In that case, "staff might put out the resident's clothes in the proper order within his reach," says Gross. The person could then don his shirt, for example, and rest before putting on his pants. "That way, the person would have more energy to participate in therapy, activities and other tasks he found meaningful for the rest of the day."