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Quality of Life:

Use The MDS To Steer Clear Of The Next Survey Minefield

Published on Tue Mar 30, 2004

Stay a step ahead by developing key quality of life indicators.

Quality of life may be a provider-led movement, but it's also the next major regulatory frontier. So jump on the bandwagon before the government comes up with a checklist of quality indicators and a big enforcement stick.
 
"Facilities should take a look at what they are already doing to enhance residents' quality of life ... and use the MDS as a tool to develop quality of life indicators on their own," suggests Steven Littlehale, MSN, RN, chief clinical officer for LTCQ Inc. in Lexington, MA.

The following sections of the MDS can guide you in helping promote quality of life for each resident as he or she defines it.

  •  Section AC. This section assesses the resident's customary routine -- information you can use to make simple but meaningful changes to enhance his enjoyment of life in your facility. Completed at admission, the section asks a series of questions reflecting a one-year period prior to admission. "Some facilities use section AC to begin a dialogue with residents and families," Littlehale notes. "They say, 'We really want to know what your lifestyle was before you came into the facility so we can do our best to create a similar homelike environment like you are used to.'"

    Examples: If a resident has a distinct food preference noted on this section, make sure that it's noted in the dietitian's notes and actually appears on the resident's meal tray.

    If a resident notes in Section AC that he finds strength in faith, make sure the person has access to religious or spiritual events, such as services and prayer groups.

    "People with cognitive impairment are often comforted by religious activities," Littlehale notes. "Even patients with late stages of dementia often show signs of relaxation or serenity when they hear religious songs from their past or have someone read familiar scripture to them," Littlehale says.

  •  Section N (activity patterns). This section includes five questions that assess how the resident spends his day, including whether the person wants to change his activities. "By using these five items in Section N, you can think of a dozen indicators for quality of life," Littlehale says.

    Consider this: If you repeatedly see that the resident has indicated on Section N that he'd like to see a change in activities, what has the facility done about that? If the resident has checked "gardening and plants," as an activity of interest, there are a lot of activities a facility could implement -- for example, an herbal garden or a program about gardening or a visit to a garden or gardening center for those able to participate. "The person with dementia might enjoy a program where you put potted plants on a table and lift her hands to put them in the dirt and help her plant seeds and then water the plants as they grow," Littlehale suggests.

    Individualize activities to meet the needs of different populations in your facility, including younger residents and those with dementia, advises Patricia Boyer, MSN, RN, a consultant with the Milwaukee office of BDO Seidman Inc. Surveyors are handing out more F tags for failure to do so as part the government's growing focus on activities as a key part of quality of life, Boyer reports.

  •  Section F (psychosocial wellbeing). This MDS section looks at the resident's ability to engage in life at the facility. "Studies link engagement in facility life to mortality," Littlehale reminds facilities.

    "Depression and social isolation are two key indicators that show a resident may not be involved in the facility life," says Boyer. That means you should take another look at residents who seldom come out of their rooms.

    What's one of the best ways to improve resident's engagement in facility life? Give residents choices in their daily care whenever possible, advises Littlehale. Start by giving the resident an opportunity to make one choice in her caregiving day and build from there. "A cognitively intact person can choose her clothing items, such as a shirt or blouse. A cognitively impaired person can choose between two shirts held up by the caregiver." Then as the person adapts to making that one choice daily, slowly widen his horizon of options. "This helps the resident feel involved in the daily routine," says Littlehale.

    To counter loneliness and isolation, consider using primary nursing assistant models where the same CNAs consistently work with the same assigned residents. "Quality of life is about relationships, and to build relationships, it's essential that CNAs have primary assignments that don't rotate," emphasizes Paul Hollings, executive director of the Neville Center at Fresh Pond in Cambridge, MA.

    "The CNAs should attend care plan meetings on a routine basis and be empowered to make decisions as front-line caregivers -- to order trays or call to get a room cleaned -- without having to go through the charge nurse, which can bottleneck service," Hollings adds.

    Develop Physical Proxies for QoL

    Quality of life also involves very basic things like having good oral health (Sections K and  L) and adequate pain management (Section J). "Quality of care definitely plays into the quality of life -- that may be why surveyors tend to focus on issues such as incontinence and pressure ulcers," says Littlehale. The good news is that you can use physical indicators as proxy indicators for quality of life. For example, staff should carefully evaluate residents with low vision to improve their quality of life through the use of vision aids and by organizing the environment to promote security.

    Don't miss this key indicator: Pay special attention to the dental/oral health items in Section L1. "Quality of life can't be optimal when you have bad gum disease or broken, loose or decayed teeth," notes geriatric dentist Greg Folse in Lafayette, LA, who consults with the Louisiana state government and the Centers for Medicare & Medicaid Services on dental/oral health issues.

    Sage advice: When using physical indicators to reflect quality of life, keep in mind the resident's perspective, Littlehale advises. "The resident may not want to wear his dentures except at meals -- or maybe never," he notes. Make sure to document the resident's wishes, and your attempts to explain to him the consequences of choices that could affect his wellbeing. Also, never assume that someone who is in a certain physical condition -- for example, paralyzed or in the late stages of cancer -- cannot achieve a meaningful and quality level of life as defined by that person and his loved ones, Littlehale offers.

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