MDS Alert

Published on Mon Oct 27, 2008 PDF

Question: Should a nursing facility code significant weight loss in Section K if it's a planned weight loss for someone who is overweight and voluntarily participates in a weight-reduction plan?

Answer: The facility must code a weight loss that meets the criteria for coding in Section K regardless of the reason for the weight loss, says Rena Shephard, MHA, RN, RAC-MT, C-NE, president of RRS Healthcare Consulting in San Diego, and founding chair and executive editor for the American Association of Nurse Assessment Coordinators. "The weight loss will trigger the Resident Assessment Protocol (RAP), and the reasons for the weight loss will be captured in that further, in-depth assessment." The care plan can be adjusted accordingly, as necessary, she says.

Question: What does the revised F325 survey guidance say about using prealbumin and albumin in nutritional assessment and monitoring? How should care providers interpret the test results?

Answer: According to the revised guidance, "serum albumin may help establish prognosis but is only sometimes helpful in identifying impaired nutrition or guiding interventions. Serum albumin may drop significantly during an acute illness for reasons unrelated to nutrition; therefore, albumin may not improve, or may fall further, despite consumption of adequate amounts of calories and protein."

The guidance further states that "although laboratory tests such as albumin and prealbumin may help in some cases in deciding to initiate nutritional interventions, there is no evidence that they are useful for the serial follow-up of undernourished individuals."

More advice: "It used to be standard operating procedure to do an albumin or prealbumin level on someone with a pressure ulcer," says nutritional expert Annette Kobriger, RD, CD, MPH, MPA, president of Kobriger Presents in Chilton, WI. But when someone is under physiological stress, his albumin and pre-albumin level drops when the protein comes out of the vascular system and travels to the place of injury, Kobriger continues. As a result, people have to know when an albumin or prealbumin level is valid or not, she says.

Cautionary example: Kobriger points to a lawsuit involving a nursing home resident with a pressure ulcer who had dropping albumin levels. The lawsuit claimed that the resident's nutrition was poor in the nursing facility, as indicated by the low albumin. When the resident went to the hospital and received flap surgery for the pressure ulcer and IV antibiotics for an infection, her albumin level went up. "But she was sick and under stress with the stage 4 ulcer in the nursing home. Once that was treated and the infection cleared, her albumin level came back up -- not because her nutritional status had improved but because her disease process was clinically resolving."