MDS Alert

Identify residents who really need a turning and repositioning program.

Facilities that automatically turn and reposition every resident who triggers on the pressure ulcer RAP may end up taking the rap come survey time.

That's because the path to F tags is often paved with good intentions that staff can't implement consistently.

Know the statistical reality: Sixty percent of nursing home residents, on average, trigger the pressure ulcer RAP. And there's no way nursing staff can turn and reposition all of them every two hours, says Barbara Bates-Jensen, PhD, RN, CWOCN, at the ULCA Borun Center for Gerontological Research at the Los Angeles Jewish Home for the Aging. As a result, none of the residents receives this critical intervention on time, she cautions. "And then the high-risk people develop pressure ulcers."

Also, facilities that say they are going to do something--and then don't follow through--set themselves up for survey liability and the risk of litigation, cautions Kathleen Thimsen, RN, ET, MSN, president of RARE Consulting Inc. in Bella Vista, AR. 

The solution: The licensed nursing staff can do a physical performance test to look at whether a particular resident can turn independently in bed. Bates-Jensen recommends performing the test on residents who trigger on the RAP and also have a certain risk score on the Braden Scale. For example, a score of 16 for nursing homes is considered the cutoff for being at risk for skin breakdown, she says. "The test only takes about six minutes to perform."

A resident "passes" the performance test if he can turn with a verbal command or verbal cue, says Bates-Jensen. But if he requires any physical contact to turn, he fails the test. 

Bates-Jensen notes that "some residents may be physically able to move but cognitively impaired such that they require assistance at least verbally." But providing verbal reminders to reposition takes "far less time than actually performing the turn for the patient," she notes.

Know When To Do Additional Performance Assessments

How often should you re-administer the performance test to residents who continue to trigger on the pressure ulcer RAP?

"At least quarterly and whenever they have a change in condition," instructs Bates-Jensen. Residents who can move side to side on their own in bed may need additional bed mobility assessment when they first start taking a psychoactive medication or pain medication, cautions Bates-Jensen. "In addition, residents with an acute illness, such as the flu, who are normally independent in bed mobility may require assessment and potential assistance [to turn and reposition] to prevent skin breakdown."

Beware: Some residents may need turning every 30 minutes and more sophisticated pressure relief interventions to prevent skin breakdown, notes Julie Thurn-Favilla, RN, a clinical consultant with the Milwaukee office of LarsonAllen.

"The interdisciplinary staff needs to complete a risk assessment--and assessment of the person's skin--to support the individualized turning and repositioning schedule," counsels Thurn-Favilla.

Differentiate Between Performance Test, ADL Assessment

Staff may get confused about  the difference between doing the performance test and assessing bed mobility to code the MDS.

The performance test for positioning focuses on the person's ability in a self-care capacity--what the person can do, notes Cleo Boulter, MSN, RN, VP of clinical reimbursement Home Quality Management in Beach Gardens, FL.

By contrast, "the MDS focuses on the person's actual performance over the last seven days and the most support the person required even once," Boulter emphasizes. "That's an important distinction" to make, she adds.