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Survey Management:

Code These Risks And Rx - Or Risk Getting Blamed

Published on Tue Feb 08, 2005 Print Friendly and PDF PDF

Picture this: A surveyor or DAVE reviewer asks to compare her assessment of a resident with a pressure ulcer to what you've scored on the MDS.

That scenario's no sweat if you make sure the MDS captures all of the resident's risks and how the facility has addressed each one.

To avoid taking the rap for missing risk factors, use the RAP as your guide. The RAP key for pressure ulcers provides a checklist for what to look for when assessing a resident with a pressure ulcer, says Rena Shephard, RN, FACDONA, MHA, president of RRS Healthcare Consulting in San Diego (see the "Clip 'N Save," later in this issue).

Don't overlook depression (Section E) and sedation (Section N1) as factors that up the ante for preventing decubiti. Residents who are depressed and/or sedated may have limited physical mobility and need encouragement to move to prevent skin breakdown, observes Nemcy Cavite Duran, RN, BSN, CRNAC, MDS director for Dr. William O. Benenson Rehabilitation Pavilion in Flushing, NY.

Depressed individuals may also drink and eat insufficient amounts, which places them at risk for pressure ulcers, cautions Duran.

Check Section J2: Pain that interferes with mobility or affects mood may contribute to immobility and increase the risk of a pressure ulcer developing - or delay healing of an existing pressure ulcer, warns the Centers for Medicare & Medicaid Services in revised survey guidance for F314.

Cognitive impairment also places a resident at risk for forgetting to reposition without staff reminders or assistance. "Wheel- chair-bound residents coded as having short-term memory loss on the MDS will need reminders at specified intervals to reposition based on their risk of skin breakdown," advises Reta Underwood, a consultant in Louisville, KY.

Capture Your Care

Take credit for everything the staff is doing to prevent or treat a wound - and look for potential care plan shortfalls in the process. The RAP key can also be useful in that regard, because it includes what to address in a resident with a pressure ulcer, says Shephard.

Check to see if you're providing and coding these interventions:

  • Liquid supplements between meals. If you're providing this nutritional intervention, take credit for it on the care plan and in Sections K5 and M5, advises Karen Merk, RN, a former DON and currently a clinical consultant with Briggs Corporation in West Des Moines, IA.

  • Dressings to the feet. "If the resident has an ulcer on the lower extremity being treated with [those interventions], check to see you've coded them at M6f," advises Duran.

  • A turning and repositioning program at M5c. To code this item, the facility has to have a program that is "organized, planned, documented, monitored and evaluated," according to an August 2003 RAI manual update.

    "And some facilities aren't going that extra step to do what it takes to be able to code their turning and repositioning on the MDS," says Susan Campion, RN, CDONA, North Florida Rehab. & Specialty Care in Gainesville. As a result, "those facilities may not appear to be doing as much as they really are to prevent pressure ulcers," she adds.

    Solution: Re-evaluate your documentation and care planning systems to see if the facility is indeed providing turning and positioning that would qualify as a "program" based on the RAI manual definition. If not, consider making changes to allow the facility to capture this key preventive service.

    Tips: Use a flow chart to document that staff reminded residents with short-term memory loss to reposition themselves in a wheelchair or other chair at designated intervals - and that the resident actually did so independently or with staff's help.
    If the resident has impaired bed mobility coded in Section G, check to see if you've checked M5c (turning/ repositioning program), Duran says.

  • Foot care (M6e). If the resident has diabetes mellitus or peripheral vascular disease checked in Section I, make sure you're doing (and coding) preventive, protective foot care in M6e, says Duran.

  • Restorative nursing (P3). "Get restorative nursing involved in doing preventive care for residents with moderate to high risk of skin breakdown," advises Kathleen Thimsen, RN, ET, MSN, president of RARE Consulting Group in Bella Vista, AR.

    Tip: Residents unable to reposition themselves without some assistance, including cueing, receive restorative nursing to prevent pressure ulcers at Betz Nursing Home in Auburn, IN, reports Nancy Woodcox, the MDS coordinator for the facility.
     
    Sometimes facilities don't take credit in Section M5 for pressure-relieving devices in the bed and chair, such as a gel cushion, observes Merk. The care plan should also reflect the locations (bed, wheelchair, dining room, etc.) where the facility is using the devices, Merk says.

    To code or not to code pressure-reduction devices? The Centers for Medicare & Medicaid Services says it will clarify the difference between pressure-relieving and pressure-reducing devices in an upcoming RAI manual update, says Nancy Augustine, RN, MSN, a consultant with LTCQ Inc. in Lexing-ton, MA.

    "Meantime, if the manufacturer doesn't say in writing that its product  is pressure-relieving, then the facility really should not code it in Section
    M -  if it's following the RAI user's manual instructions to the 'T'," cautions Augustine.

    But beware: If a resident develops a pressure ulcer and there's no device checked in Section M - and no documentation to show that a pressure reduction or relief device was used - surveyors will closely examine whether the ulcer was unavoidable, Augustine notes.

    Tip: Develop a risk-based matrix that dictates what type of device is appropriate based on the resident's risk level, advises Augustine.

    Editor's note: For details on assessing and coding wound severity, including infection, see the April 2005 MDS Alert.

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