Nursing home Five-Star quality ratings, increasing MDS focused surveys and resident expectations put nursing home care systems under the microscope with the MDS assessment data right in the middle of the target. It is clear our governing bodies, as well as families and loved ones, want to know which nursing homes can take the best care of those they love. This is a concept that resonates with a universal heartbeat for which all in the care continuum.
The dilemma is how that information is measured and communicated to the public, knowing that it will be data-driven only and without any emotion or love attached to it. With that said, it is now our responsibility to ensure all of the data accurately reflects all residents and the care that is being provided to them.
The MDS 3.0 has evolved into much more than a comprehensive assessment tool for residents in a skilled nursing facility (SNF). It is a data-packed tool that drives care, reimbursement, and now, quality outcomes. The data inside every MDS section must accurately reflect each resident according to the Resident Assessment Instrument (RAI) rules for coding.
However, many of the sections of the MDS can be confusing to code and have some inherent pitfalls when careful attention is not given to the specific RAI rules and guidelines. Facility leaders are required not only to understand the changes but also to strategize and understand the data and outcomes. In the face of this necessity, the burning question of the day becomes: “Where do I start?”
Know the data and pitfalls
Quality measures (QMs) are driven by MDS 3.0 data. Many of the items on the MDS have very tricky coding rules, making them highly susceptible to errors. For example, items in section M, “Skin Conditions,” have a number of very specific coding tips that, if not adhered to, can compromise the QMs for New or Worsened Pressure Ulcers (short stay) and High-Risk Residents with Pressure Ulcers (long stay). Here are some examples:
- Pressure ulcers that become unstageable are not worsened.
- Pressure ulcers that are “present on admission” are not worsened.
- Unstageable pressure ulcers debrided for the first time are not worsened.
- When a debrided ulcer becomes unstageable and then is debrided again, compare previous stage to current stage to determine if the ulcer has worsened.
It is important to know the source of the data for each QM as well as the coding rules from the RAI. The following are other vulnerable areas that can compromise data integrity.
Urinary Tract Infection (I2300). There are four conditions that have to be met before coding a UTI in the last 30 days:
- Diagnosis of a UTI in the last 30 days
- Sign or symptom of a UTI
- Significant laboratory findings
- Active medication or treatment in the last 30 days
Physical Restraints (P0100A-H). It is important to understand the definition of restraint and the effect the device has on the resident before coding. The decision whether to code a device as a restraint is made after an interdisciplinary discussion and review.
ADLs (G0110A, B, H, I). The four late-loss ADLs (bed mobility, transfers, eating and toileting) are some of the most frequently miscoded items on the MDS. The coding rules include guidance using a system called the Rule of 3, which can confuse even the best of MDS nurses.
The importance of having a system for evaluating and validating data cannot be understated. It is recommended that facility leaders use an inter-rater review, where two people complete the same MDS for a resident. If both reviewers code with the same answers and end up with a measurable outcome, the data can be considered both reliable and valid.
Be alert for resident referrals
Many residents are in the denominators of problematic QMs and are in need of interventions. Identifying those residents in a proactive fashion can help to prevent negative outcomes. Most residents in the nursing home are appropriate for restorative programs and/or therapy interventions. These kinds of programs are inherently designed to help attain or maintain the resident’s highest practicable physical, mental and psychosocial well-being—marching orders that, when followed through solid care planning and delivery of services, will promote quality for all residents. Once again, however, the question lingers: “Where do I start?”
Most providers have built a number of risk assessments into their care-delivery systems. Managing risk factors is the first step to having good quality outcomes. For example, when a resident is admitted to a facility, Nursing completes a number of these risk assessments, which may include a Fall Risk Assessment, a Braden or Norton for skin, and a Bowel and Bladder Assessment.
These assessments are designed to extract specific factors that put the resident at risk for a negative outcome. They can also point to opportunities to prevent a negative outcome. For example, a resident may be at risk for skin breakdown because of impaired bed mobility. A restorative program for bed mobility may be appropriate.