MDS Alert

Published on Mon Jul 23, 2012 PDF

Hone your coding skills with these RAI patient scenarios

E0100: Potential Indicators of Psychosis

RAI Coding Instructions:

Code based on behaviors observed and/or thoughts expressed in the last 7 days rather than the presence of a medical diagnosis. Check all that apply.

• Check E0100A, hallucinations: if hallucinations were present in the last 7 days. A hallucination is the perception of the presence of something that is not actually there. It may be auditory or visual or involve smells, tastes or touch.
• Check E0100B, delusions: if delusions were present in the last 7 days. A delusion is a fixed, false belief not shared by others that the resident holds true even in the face of evidence to the contrary.
• Check E0100Z, none of the above: if no hallucinations or delusions were present in the last 7 days.

RAI Manual Coding Tips and Special Populations:

• If a belief cannot be objectively shown to be false, or it is not possible to determine whether it is false, do not code it as a delusion.
• If a resident expresses a false belief but easily accepts a reasonable alternative explanation, do not code it as a delusion. If the resident continues to insist that the belief is correct despite an explanation or direct evidence to the contrary, code as a delusion.

RAI Scenario No. 1: A resident carries a doll which she believes is her baby and the resident appears upset. When asked about this, she reports she is distressed from hearing her baby crying and thinks she's hungry and wants to get her a bottle.

RAI Scenario No. 2: A resident reports that he heard a gunshot. In fact, there was a loud knock on the door. When this is explained to him, he accepts the alternative interpretation of the loud noise.

RAI Scenario No. 3: A resident is found speaking aloud in her room. When asked about this, she states that she is answering a question posed to her by the gentleman in front of her. Staff note that no one is present and that no other voices can be heard in the environment.

RAI Scenario No. 4: A resident announces that he must leave to go to work, because he is needed in his office right away. In fact, he has been retired for 15 years. When reminded of this, he continues to insist that he must get to his office.

RAI Scenario No. 5: A resident believes she must leave the facility immediately because her mother is waiting for her to return home. Staff know that, in reality, her mother is deceased and gently remind her that her mother is no longer living. In response to this reminder, the resident acknowledges, "Oh yes, I remember now. Mother passed away years ago."

E0200: Behavioral Symptom -- Presence & Frequency

RAI Coding Instructions:

Code 0, behavior not exhibited: if the behavioral symptoms were not present in the last 7 days. Use this code if the symptom has never been exhibited or if it previously has been exhibited but has been absent in the last 7 days.

Code 1, behavior of this type occurred 1-3 days: if the behavior was exhibited 1-3 days of the last 7 days, regardless of the number or severity of episodes that occur on any one of those days.›› ››

Code 2, behavior of this type occurred 4-6 days, but less than daily: if the behavior was exhibited 4-6 of the last 7 days, regardless of the number or severity of episodes that occur on any of those days.

Code 3, behavior of this type occurred daily: if the behavior was exhibited daily, regardless of the number or severity of episodes that occur on any of those days.

RAI Coding Tips and Special Populations:

• Code based on whether the symptoms occurred and not based on an interpretation of the behavior's meaning, cause or the assessor's judgment that the behavior can be explained or should be tolerated.
• Code as present, even if staff have become used to the behavior or view it as typical or tolerable.
• Behaviors in these categories should be coded as present or not present, whether or not they might represent a rejection of care.
• Item E0200C does not include wandering.

RAI Scenario No. 1: Every morning, a nursing assistant tries to help a resident who is unable to dress himself. On the last 4 of 6 mornings, the resident has hit or scratched the nursing assistant during attempts to dress him.

RAI Scenario No. 2: A resident has previously been found rummaging through the clothes in her roommate's dresser drawer. This behavior has not been observed by staff or reported by others in the last 7 days.

RAI Scenario No. 3: A resident throws his dinner tray at another resident who repeatedly spit food at him during dinner. This is a single, isolated incident.

E0500A, B, C: Impact on Resident

RAI Coding Instructions for E0500A. Did Any of the Identified Symptom(s) Put the Resident at Significant Risk for Physical Illness or Injury?:

• Code 0, no: if none of the identified behavioral symptom(s) placed the resident at clinically significant risk for a physical illness or injury.
• Code 1, yes: if any of the identified behavioral symptom(s) placed the resident at clinically significant risk for a physical illness or injury, even if no injury occurred.

RAI Coding Instructions for E0500B: Did Any of the Identified Symptom(s) Significantly Interfere with the Resident's Care?

• Code 0, no: if none of the identified behavioral symptom(s) significantly interfered with the resident's care.
• Code 1, yes: if any of the identified behavioral symptom(s) impeded the delivery of essential medical, nursing, rehabilitative or personal care, including but not limited to assistance with activities of daily living, such as bathing, dressing, feeding, or toileting.

RAI Coding Instructions for E0500C: Did Any of the Identified Symptom(s) Significantly Interfere with the Resident's Participation in Activities or Social Interactions?

• Code 0, no: if none of the identified symptom(s) significantly interfered with the resident's participation in activities or social interactions.
• Code 1, yes: if any of the identified behavioral symptom(s) significantly interfered with or decreased the resident's participation or caused staff not to include residents in activities or social interactions.

RAI Coding Tips and Special Populations:

• For E0500A, code based on whether the risk for physical injury or illness is known to occur commonly under similar circumstances (i.e., with residents who exhibit similar behavior in a similar environment). Physical injury is trauma that results in pain or other distressing physical symptoms, impaired organ function, physical disability, or other adverse consequences, regardless of the need for medical, surgical, nursing, or rehabilitative intervention.
• For E0500B, code if the impact of the resident's behavior is impeding the delivery of care to such an extent that necessary or essential care (medical, nursing, rehabilitative or personal that is required to achieve the resident's goals for health and well-being) cannot be received safely, completely, or in a timely way without more than a minimal accommodation, such as simple changes in care routines or environment.
• For E0500C, code if the impact of the resident's behavior is limiting or keeping the resident from engaging in solitary activities or hobbies, joining groups, or attending programmed activities or having positive social encounters with visitors, other residents, or staff.

RAI Scenario No. 1: A resident frequently grabs and scratches staff when they attempt to change her soiled brief, digging her nails into their skin. This makes it difficult to complete the care task.

RAI Scenario No. 2: During the last 7 days, a resident with vascular dementia and severe hypertension, hits staff during incontinent care making it very difficult to change her. Six out of the last 7 days the resident refuses all her medications including her antihypertensive. The resident would close her mouth and shake her head and would not take the medication even if re-approached multiple times.

RAI Scenario No. 3: A resident paces incessantly. When staff encourage him to sit at the dinner table, he returns to pacing after less than a minute, even after cueing and reminders. He is so restless that he cannot sit still long enough to feed himself or receive assistance in obtaining adequate nutrition.

RAI Scenario No. 4: A resident repeatedly throws his markers and card on the floor during bingo.

RAI Scenario No. 5: A resident with severe dementia has continuous outbursts while awake despite all efforts made by staff to address the issue, including trying to involve the resident in prior activities of choice.

E0600A, B, C: Impact on Others

RAI Coding Instructions for E0600A: Did Any of the Identified Symptom(s) Put Others at Significant Risk for Physical Injury?

• Code 0, no: if none of the identified behavioral symptom(s) placed staff, visitors, or other residents at significant risk for physical injury.
• Code 1, yes: if any of the identified behavioral symptom(s) placed staff, visitors, or other residents at significant risk for physical injury.

RAI coding Instructions for E0600B: Did Any of the Identified Symptom(s) Significantly Intrude on the Privacy or Activity of Others?

• Code 0, no: if none of the identified behavioral symptom(s) significantly intruded on the privacy or activity of others.
• Code 1, yes: if any of the identified behavioral symptom(s) kept other residents from enjoying privacy or engaging in informal activities (not organized or run by staff). Including coming in uninvited, invading, or forcing oneself on others' private activities.

RAI Coding Instructions for E0600C: Did Any of the Identified Symptom(s) Significantly Disrupt Care or the Living Environment?

• Code 0, no: if none of the identified behavioral symptom(s) significantly disrupted delivery of care or the living environment.
• Code 1, yes: if any of the identified behavioral symptom(s) created a climate of excessive noise or interfered with the receipt of care or participation in organized activities by other residents.

Coding Tips and Special Populations

• For E0600A, code based on whether the behavior placed others at significant risk for physical injury. Physical injury is trauma that results in pain or other distressing physical symptoms, impaired organ function, physical disability or other adverse consequences, regardless of the need for medical, surgical, nursing, or rehabilitative intervention.
• For E0600B, code based on whether the behavior violates other residents' privacy or interrupts other residents' performance of activities of daily living or limits engagement in or enjoyment of informal social or recreational activities to such an extent that it causes the other residents to experience distress (e.g., displeasure or annoyance) or inconvenience, whether or not the other residents complain.
• For E0600C, code based on whether the behavior interferes with staff ability to deliver care or conduct organized activities, interrupts receipt of care or participation in organized activities by other residents, and/or causes other residents to experience distress or adverse consequences.

RAI Scenario No. 1: A resident appears to intentionally stick his cane out when another resident walks by.

RAI Scenario No. 2: A resident, when sitting in the hallway outside the community activity room, continually yells, repeating the same phrase. The yelling can be heard by other residents in the hallway and activity/recreational areas but not in their private rooms.

RAI Scenario No. 3: A resident repeatedly enters the rooms of other residents and rummages through their personal belongings. The other residents do not express annoyance.›› ››

RAI Scenario No. 4: When eating in the dining room, a resident frequently grabs food off the plates of other residents. Although their food is replaced, so the behavior does not compromise their nutrition, other residents become anxious in anticipation of this recurring behavior.

RAI Scenario No. 5: A resident tries to seize the telephone out of the hand of another resident who is attempting to complete a private conversation. Despite being asked to stop, the resident persists in grabbing the telephone and insisting that he wants to use it.

RAI Scenario No. 6: A resident begins taunting two residents who are playing an informal card game, yelling that they will "burn in hell" if they don't stop "gambling."

RAI Scenario No. 7: A resident yells continuously during an exercise group, diverting staff attention so that others cannot participate in and enjoy the activity.

RAI Scenario No. 8: A resident becomes verbally threatening in a group discussion activity, frightening other residents. In response to this disruption, staff terminate the discussion group early to avoid eliciting the behavioral symptom.

E0800: Rejection of Care -- Presence & Frequency

RAI Coding Instructions:

Code 0, behavior not exhibited: if rejection of care consistent with goals was not exhibited in the last 7 days.

Code 1, behavior of this type occurred 1-3 days: if the resident rejected care consistent with goals 1-3 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days.

Code 2, behavior of this type occurred 4-6 days, but less than daily: if the resident rejected care consistent with goals 4-6 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days.

Code 3, behavior of this type occurred daily: if the resident rejected care consistent with goals daily in the 7-day-look-back period, regardless of the number of episodes that occurred on any one of those days.

RAI Coding Tips and Special Populations:

• The intent of this item is to identify potential behavioral problems, not situations in which care has been rejected based on a choice that is consistent with the resident's preferences or goals for health and well-being or a choice made on behalf of the resident by a family member or other proxy decision maker.
• Do not include behaviors that have already been addressed (e.g., by discussion or care planning with the resident or family) and determined to be consistent with the resident's values, preferences, or goals. Residents who have made an informed choice about not wanting a particular treatment, procedure, etc., should not be identified as "rejecting care."

RAI Scenario No. 1: A resident with heart failure who recently returned to the nursing home after surgical repair of a hip fracture is offered physical therapy and declines. She says that she gets too short of breath when she tries to walk even a short distance, making physical therapy intolerable. She does not expect to walk again and does not want to try. Her physician has discussed this with her and has indicated that her prognosis for regaining ambulatory function is poor.

RAI Scenario No. 2: A resident informs the staff that he would rather receive care at home, and the next day he calls for a taxi and exits the nursing facility. When staff try to persuade him to return, he firmly states, "Leave me alone. I always swore I'd never go to a nursing home. I'll get by with my visiting nurse service at home again." He is not exhibiting signs of disorientation, confusion, or psychosis and has never been judged incompetent.

RAI Scenario No. 3: A resident goes to bed at night without changing out of the clothes he wore during the day. When a nursing assistant offers to help him get undressed, he declines, stating that he prefers to sleep in his clothes tonight. The clothes are wet with urine. This has happened 2 of the past 5 days. The resident was previously fastidious, recently has expressed embarrassment at being incontinent, and has care goals that include maintaining personal hygiene and skin integrity.

RAI Scenario No. 4: A resident chooses not to eat supper one day, stating that the food causes her diarrhea. She says she knows she needs to eat and does not wish to compromise her nutrition, but she is more distressed by the diarrhea than by the prospect of losing weight.

RAI Scenario No. 5: A resident is given his antibiotic medication prescribed for treatment of pneumonia and immediately spits the pills out on the floor. This resident's assessment indicates that he does not have any swallowing problems. This happened on each of the last 4 days. The resident's advance directive indicates that he would choose to take antibiotics to treat a potentially life-threatening infection.

RAI Scenario No. 6: A resident who recently returned to the nursing home after surgery for a hip fracture is offered physical therapy and declines. She states that she wants to walk again but is afraid of falling. This occurred on 4 days during the look-back period.

RAI Scenario No. 7: A resident who previously ate well and prided herself on following a healthy diet has been refusing to eat every day for the past 2 weeks. She complains that the food is boring and that she feels full after just a few bites. She says she wants to eat to maintain her weight and avoid getting sick, but she cannot push herself to eat anymore.

Source: The Long-Term Care Facility Resident Assessment Instruments User's Manual MDS 3.0, V1.08 (April 2012).