MDS Alert

Question: A certified nurse aide (CNA) documented that a resident can sit up in bed by herself, but I know this resident has some health conditions that limit her mobility. Are there any ways I can clarify “by herself” for the CNA without sounding rude?

Kansas Subscriber

Answer: The Resident Assessment Instrument (RAI) Manual provides guidance for MDS item GG0170 (Mobility (3-day assessment period) Admission/Interim/Discharge (Start/Interim/End of Medicare Part A Stay) saying that accurately assessing a resident’s mobility may involve asking other team members, particularly those who are providing direct care, “probing” questions. The MDS offers several coding options to reflect the assessment for subitem GG0170B (Mobility (3-day assessment period) Admission/Interim/Discharge (Start/Interim/End of Medicare Part A Stay; Sit to lying).

In this situation, you could simply ask the CNA whether the resident needed any verbal reminders or light physical assistance to move from a lying down position in bed to a sitting position on the side of the bed. If the CNA says that a resident needs verbal reminders for where to place her arms to maneuver her body into the sitting position, you should consider the resident needing supervision or touching assistance, which is coding choice 04.

The MDS describes supervision or touching assistance as “04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.”