Long-Term Care Survey Alert

1. Has the resident shown decline or lack of expected improvement in any ADLs coded in Section G since the last MDS assessment? Yes ___ No ___

If yes, list the coding for the previous and most recent MDS.

Coding previous MDS Coding this MDS

A. Transfer

B. Toileting

C. Bed mobility

D. Eating

E. Bathing

F. Dressing

2. Has the person shown a decline in mobility? Describe briefly._______________________________________________

3. Has the resident received rehab therapy or restorative nursing in the last 90 days? _______________________________

4. Does the resident now require an assistive device not coded on the previous assessment? Yes__ No__

5. What type of device is now being used? Circle: wheelchair,walker, cane, other ____

6. Does the resident or staff now perceive the person could do more of his ADLs independently? Yes__ No__

7. Has the person experienced a decline in functional limitation in range of motion coded at G4? Yes __ No__

Describe briefly _____________________________________

8. Check if the resident has experienced any other areas of decline or failure to improve as expected below:

___ Cognition (more impaired in daily decision-making at

B4 and/or now has short-term memory loss)

___ Communication/Hearing

___ Vision

___ Weight loss (including insidious weight loss that isn't

sufficient to code in Section K)

___ Change in diet or dietary intake

___ Stability of conditions (J5)

___ Fall(s)

___ Other

9. Could an acute or chronic condition(s) or treatment(s) explain the decline or failure to improve? Circle all that might apply: Parkinson's disease, stroke, COPD, flu, pneumonia, surgery,depression, dementia, heart attack, cancer, congestive heart failure, renal failure, dialysis, radiation, other _________

10. Has the resident started on any new medication(s) or changes in dosage that coincide with the ADL decline? If yes, the names and dosage of the medication(s)

__________________________________________________

11. Has the resident had a formal medication review? Findings __________________________________________

12. Does the resident appear to be a candidate for hospice? __ Yes __ No

13. The resident is triggering the following QIs/QMs: ___________________________________________

14. Do any of these have hospice as an exclusion? Yes __ No__

15. If the resident isn't triggering on the pain QM, does he have pain? Are his pain goals being met? ______

16. Does the resident's decline qualify as a significant change in status? Yes__ No ___ Rationale: _____________________

New problems identified, if SCSA completed:

1. __________________________________

2. __________________________________

3. __________________________________

17. Has the resident received a rehab therapy screen or evaluation?

___ Yes ___ No. Findings/recommendations:

___________________________________________________

___________________________________________________

18. Has the resident received a restorative nursing evaluation?

___ Yes ___ No. Findings/recommendations:

___________________________________________________

___________________________________________________

19. Other evaluations : medical ____ psychosocial ____

dietary ____ other ________________________

20. Summary of key findings/changes in treatment plan:

___________________________________________________

___________________________________________________

___________________________________________________

Source: Developed by Eli Healthcare.