MDS Alert

Question: In our facility, certified nurse assistants (CNAs) do a lot of the charting for activities of daily living (ADLs). We have a resident who I know, from my own observation, requires extensive assistance for a number of ADLs; I would definitely classify him as “substantial/maximal assistance” for bed mobility and toileting. However, the CNA’s charting instead suggests that he requires only “partial/moderate assistance.” The reality of the resident’s needs would mean a higher resource utilization group (RUG) level, and I’m worried that surveyors may be skeptical about a change to the chart. Can I change her documentation to reflect the resident’s actual situation without arousing suspicion?

Codify Subscriber

Answer: Although submitting a correction may be intimidating, striving for accuracy in both the clinical record and any assessments should be a top priority for each facility.

Texas Health and Human Services has addressed this topic, saying:

“… Providers have stated that they have been told that they cannot change the documentation that has been entered by the Certified Nursing Assistants (CNAs). This is correct, you cannot edit the ADL coding entered into the nursing assistant charting, but you must ensure that if this information pre-populates the Minimum Data Set (MDS) that it is accurate … The MDS Coordinator (MDSC) should enter the correct coding and make a note to explain why this change was made. Most software system[s] offer an option to make a progress note right in the MDS, but if your software does not, a nursing/MDS note should be created.”

While you should always check your own local and state laws, it’s also wise to put a policy down on paper for your individual facility’s protocols for such a situation, and how a nurse assessment coordinator (or anyone else) should make this type of correction, if needed.

Don’t forget to utilize this situation as a teaching opportunity, to remind your team of the significance of accurate documentation. Explain the qualifiers that distinguish the varying levels of staff assistance for ADLs and consider posting a little chart with the Resident Assessment Instrument (RAI) definitions for assistance on each computer that staff uses to input documentation, so they don’t necessarily have to rely on their memories.