MDS Alert

Sidestep nursing board actions, IJ citations and payment recoupments.

With RACs on the loose and surveyors eager to hand out F tags, your facility might be wise to see how it's handling these two areas:

1. A physician order that seems out of line. "Nursing home staff need to question physician orders that don't seem to be advisable to follow," says attorney Neville Bilimoria, partner, Duane Morris LLP in Chicago. He handled a situation where a nurse recognized that a medication order was 10 times greater than the usual dose -- "but still an acceptable dose for some conditions." But "rather than question the order, the nurse gave the medication dosage, which was actually the wrong dose," he says.

And the resident suffered an adverse outcome, Bilimoria reports. The physician made the error, he agrees. But in such situations, state surveyors will say that the nurse should use his or her professional judgment in questioning the order and making sure the resident receives the proper dose, Bilimoria says. And that's more likely to happen if the facility has a known procedure in place to clarify orders. "The procedure should involve the medical director to oversee potentially problematic orders."

Good idea: Facilities can enlist the pharmacy to institute automatic reviews of certain medications with dosages over a specified limit -- or ones involving a significant increase in a dose compared to the previously prescribed amount. Examples of medications where you'd want to consider that strategy include morphine, methotrexate, warfarin, levothyroxine, and metoprolol, according to a presentation at the March 2009 American Medical Directors Association meeting. For a free copy of the article in Long-Term Care Survey Alert, e-mail the editor at KarenL@Eliresearch.com.

2. Days of physician order changes that qualify a resident for Clinically Complex. Under RUGIII, a resident with one or more days of physician visits (P7) and four or more days of order changes (P8) -- or two or more days of physician visits and two or more days of order changes  during the lookback will qualify for Clinically Complex, if he has the requisite ADL score. And your internal MDS audits should flag a pattern where a second order for a minor issue occurs within the assessment reference period, so that the resident goes into Clinically Complex, says Jennifer Gross, BSN, RN, RAC-CT, a healthcare specialist with PointRight in Lexington, Mass. Also, "if the MDS nurse is coding as a day of orders a continuation order such as 'Continue same dose of Coumadin' or something similar, you wouldn't count that in P8 since it isn't a new or altered treatment," adds Gross.