MDS Alert

Confusion over new or different situations could indicate ‘modified independence.’

Correct coding of item C1000 — Cognitive Skills for Daily Decision Making isn’t just important because you want your MDS assessments to be accurate. This item can reveal a lot about the state of a resident’s well-being and health status. Difficulty with daily decision-making can indicate an underlying cognitive impairment, possible anxiety or depression, or a need to assess for delirium or other medical problems.

The intent of item C1000 is to record what the resident is doing (his actual performance) in actively making decisions about tasks and activities of daily life, says Carol serici Griffin, State of Ohio RAI Coordinator with the Ohio Department of Health. So make sure you aren’t coding this item based on what the staff members believe the resident is capable of doing.

Here are four scenarios from the RAI Manual that help to demonstrate how to code item C1000:

Why Refusing Treatment Isn’t Necessarily ‘Impaired’

Scenario 1: Mr. Jones makes his own decisions on a daily basis and is reasonable and consistent in his decision-making. The only exception is that Mr. Jones constantly avoids using the walker he’s been using for nearly two years. When staff ask him why he won’t use his walker, he says he doesn’t like it and it gets in his way. He states that he doesn’t want to use the walker even though he knows that staff want him to do so.

How to code: For this scenario, you would code item C1000 as 0 — Independent. Although Mr. Jones refuses to use the walker, he is making and expressing an understanding of that decision. Additionally, other decisions he made throughout the look-back period were consistent and reasonable.

According to the RAI Manual, you should code 0 — Independent if the resident’s decisions in organizing daily routine and making decisions were consistent, reasonable, and organized reflecting lifestyle, culture, and values.

Beware: If a resident decided to exercise his right to decline treatment, this is not considered impaired decision-making, Griffin notes.

Look for Isolated Variations to Code ‘Modified Independence’

Scenario 2: Mrs. White routinely participates in coffee hour on Wednesday mornings and usually doesn’t need a reminder. But due to recent renovations, the coffee hour meeting place was moved to another location in the facility. Staff informed Mrs. White of this change and accompanied her to this new location.

Staff noticed that Mrs. White became uncharacteristically agitated and unwilling to engage with other residents and staff during coffee hour. She then left and staff found her sitting in the original meeting place. When staff asked her why she returned to this location, she said that staff had brought her to the wrong room and she would wait in this location until she’s served the coffee.

How to code: You would code item C1000 as 1 — Modified independence. Although Mrs. White is independent during routine circumstances, she had difficulty adjusting to a new or different situation.

Code 1 — Modified independence if the resident organized daily routine and made safe decisions in familiar situations, but experienced some difficulty in decision-making when faced with new tasks or situations, the RAI Manual states.

Poor Decision-Making Triggers ‘Moderately Impaired’ Coding

Scenario 3: Mr. Gordon enjoys congregate meals in the dining room and is friendly with the other residents at his table. But recently he has started to lose weight and appears to have little appetite. Mr. Gordon rarely eats without reminders from staff and willingly gives his food to other residents at his table. He requires frequent cueing to eat and supervision to prevent him from sharing his food.

How to code: Code C1000 as 2 — Moderately impaired. In this scenario, the resident is making poor decisions by giving his food away. He also requires cueing to eat and supervision to ensure that he’s eating the food on his plate.

You should code 2 — Moderately impaired if the resident’s decisions were poor, and the resident required reminders, cues, and supervision in planning, organizing, and correcting daily routines, according to the RAI Manual.

Lack of Ability to Express Needs Warrants ‘Severely Impaired’

Scenario 4: Mrs. Smith doesn’t generally make conversation or make her needs known, but she replies “yes” when asked if should would like to take a nap.

How to code: In this case, you would code item C1000 as 3 — Severely impaired. Mrs. Smith is primarily non-verbal and doesn’t make her needs known, despite giving basic verbal or non-verbal responses to simple gestures or questions.

In this scenario, it appears that Mrs. Smith’s communication of choices is limited to only specific circumstances (answering whether she would like to take a nap), which would be considered as “rarely/never” in the likely number of decisions that a resident could make during the course of a week on the MDS.

Code 3 — Severely impaired if the resident’s decision-making was severely impaired, meaning the resident never (or rarely) made his own decisions, the RAI Manual instructs.