MDS Alert

Use this simple strategy to catch a resident's significant change.

If you don't spot Medicaid residents who have lost ADL functioning until the quarterly assessment, your facility may be headed for a survey fall--and hurting its case-mix rate to boot.

"Sometimes facilities don't pick up a significant change as defined by the RAI manual until they do their quarterly reviews," observes Bet Ellis, RN, a consultant with LarsonAllen in Charlotte, NC. "And in Medicaid case-mix states that means the facility may have missed an opportunity to do the SCSA earlier and affect their case-mix," she says.

The bottom line: If someone has two or more items in his ADLs decline or improve, he has had a significant change, counsels Nathan Lake, RN, MHA, an MDS expert in Seattle. "And even though it's fairly obvious when you look for it, facilities often miss the change," he adds.

An ADL decline in two or more areas due to pneumonia is likely to be self-limited and not require an SCSA, adds Ellis. "But CNAs who work with residents on an ongoing basis may not pick up on a gradual decline--for example, in someone with Parkinson's disease," she adds.

Prompt CNAs to Compare ADL Functioning

To flag a gradual ADL decline, ask the CNAs to "ballpark" how much help residents they care for  required compared with the previous month or other designated timeframe. "Focus on the late-loss ADLs (eating, toileting, transferring and bed mobility)," suggests Ellis.

Ask the CNAs questions using the MDS nomenclature of supervision, limited assistance and extensive assistance.

For example, to assess whether the CNAs are providing supervision, Ellis advises asking them: "In assisting the resident with ADLs, do you just use your eyes and voice but don't need to touch the resident or touch him only lightly?"

To differentiate between limited or extensive assistance, ask the CNA: Who did more of the task--you or the resident? The CNAs likely provided limited assistance when the resident is doing more than the staff, says Ellis. Conversely, "extensive assistance is likely when the staff is doing more than the resident."

By using those broad categories, the CNAs can compare changes in the resident's ADL functioning. "For example, the resident may have been doing more than the staff [previously] to perform an ADL," Ellis says. "But now staff does more than the resident," she says. "And that may let you know the resident has likely moved from limited to extensive assistance," adds Ellis.