“D

ear Mabel: Our consultant told us even if we catch someone on the way down and prevent a fall, we have to count it as a fall. This doesn’t make sense to me. Is she right?” (registered nurse, New Mexico)
       Answer: Your consultant is right. Revisions published in August 2003 for the Resident Assessment Instrument (RAI) manual further clarify the definition of a fall. See page 3-146 for the new clarification of a fall. Basically, any change from one level to another lower level in which the resident has little or no control is now defined as a fall. So, yes, if someone starts to fall or stumbles and a staff member prevents a fall, it is a fall for purposes of completing the MDS. The reasoning behind this is that if a resident is unstable he or she needs further assessment and intervention to prevent future falls. By counting this change in latitude as a fall, it encourages staff to intervene quickly and completely. This change in level also applies to mattresses on the floor. If a resident is sleeping on a mattress on the floor to prevent falling out of bed, and they roll off the mattress, it counts as a fall.
       Some facilities have become quite creative in fall prevention under these new clarifications. They have placed the mattress next to a wall, and used foam bolsters (placed on non-slip material) on the opposite side of the mattress to prevent rolling off the mattress. Since the bed is up against the wall, full side rails on one side of the bed must be counted. Also, the foam bolster may not be so high as to block the residents view, or so tightly stuck to the floor the resident could not freely move it. If these conditions are not met, the bolster would also count as a full side rail. Keep this in mind when coding for restraints on Section P. Quality indicators (QIs) will also be affected by the number of falls reported in Section J of the MDS. The creativity of facilities as they attempt to meet ever more exacting standards never ceases to amaze us. Just think of it as a chance to exercise your creative talents in caring for your residents.
       “Dear Mabel: I am a new MDS co-coordinator, and it seems overwhelming. Where do I start?” (registered nurse, Louisiana)
       Answer: As the Good Witch of the North said in the Wizard of Oz, “It is always best to begin at the beginning.” The beginning and, yes, even the end of all MDS assessments are the RAI manual. Read it. When you have finished that, read it again. Get a marker and mark it up, use post it notes to mark important passages, crimp the edges of the pages to mark places, and write notes in the margin. Do whatever it takes to make the manual your own. We know we have said this repeatedly, but it is the truth.
       Next, get to know the people at the state to whom you transmit your electronic submissions. Myers and Stauffer seem to have a lock on that in most states. They are there to do a job, and part of that job is to help you. Post their number on your computer. Next, learn the name and phone number of your state MDS co-coordinator. Every state has one. There is an appendix in the back of the RAI manual that lists all the state coordinators. Then, post his or her name and phone number on your computer also. Call him or her. Introduce yourself, tell him or her of your current position, and ask for help. This person is there to help you. None of the persons we have recommended you contact are there to survey you, fine you, or make your life miserable. They do not have any investigational authority. Now, of course, if you call and tell them your facility is not submitting MDS, or some other fantastic tale, they would have to report you to the proper authority. However, just to call and ask how to code an entry or when to schedule an assessment will not cause any repercussions for you or your facility.
       There are courses offered by several companies and associations. Most are fair to good. Ask your administrator if the facility will pay for you to attend a course. In addition, if a corporation owns your facility, there may be a corporate consultant you could contact. Or you may want to consider calling a sister facility owned by your corporation and ask the MDS coordinator for help and advice.
       Scheduling is the next most important aspect of your new job after understanding coding. Chapter 2 of the RAI manual is the last word on scheduling. Your computer software may have a program to assist you with scheduling. Don’t forget the people at Myers and Stauffer. If you are in a quandary, call them. They are only a phone call away. Once you have mastered scheduling and know the definitions for coding the MDS, there is no one that will be more of an authority than you. Hard to believe, but it is true. Don’t despair; it takes time. We have found it usually takes at least three months for most clinicians to develop any proficiency. In six months, the new MDS coordinator is usually able to quote items by section letter and number. In a year, you will be giving advice and helping others. Remember, always refer to the manual for questions. Call your state MDS co-coordinator. Call you state electronic submission agency. Be proactive in getting help. If you just sit and wait for help to come to you, you might develop a pressure ulcer!
       “Dear Mabel: I am having some problems coding for a resident who has peripheral vascular disease (PVD) with arterial ulcers on his toes. What do I code, and where do I code it?” (licensed practical nurse, North Dakota)
       Answer: The development of skin ulcers is a complex issue. As the MDS becomes more intricate, it is clear to clinicians and “bean counters” alike that the attempt to codify skin lesions is a multifaceted and difficult task. Thus, it follows that Section M will always be a problem. So don’t feel bad about not understanding the instructions. First, be sure you code in Section I for PVD. In addition, try to capture any other diagnosis that might explain the development of PVD, such as diabetes or arteriosclerosis. Now, let’s consider the appropriate coding for Section M. Code the stage of all ulcers in Section M1. However, you will not be able to code for cause in Section M2. This lack of coding for a staged ulcer actually is a way of transmitting information. In your case, this lack of information is actually information. Any surveying official reviewing the assessment for this individual would know immediately there is another cause for the open area. Section M, the bane of many MDS coordinators existence, will undergo major changes in the new MDS 3.0. The hope is for a more thorough explanation of cause, classification, and cure of skin lesions.
       The MDS world continues to transform itself. The National Quality Forum (NQF), a volunteer standard-setting agency, has endorsed new quality measures. (For a better understanding of who and what this agency is, visit its website at http://www.qualityforum.org/ or call Phillip Dunn at 202-783-1300.) The 14 new proposed measures consist of seven chronic care measures, two chronic care pairs, three post-acute care measures, and two measures that would apply to all facilities. Here is a list of the chronic care measures:
1. Increased assistance with activities of daily living (ADL)
2. Moderate to severe pain at any frequency
3. Physical restraints used during the 7-day assessment period
4. Residents defined as being on bedrest
5. Decline in ability to move about in room or corridor
6. Urinary tract infections
7. Worsening of a depressed or anxious mood.
       Chronic care pairs are:
1. High-risk pressure ulcers coupled with low-risk pressure ulcers
2. Frequent loss of bowel and bladder control coupled with use of catheters.
       The post-acute measures are:
1. Moderate to severe pain
2. Symptoms of delirium
3. Pressure ulcers.
       Measures that would apply to all facilities are:
1. Pneumonia vaccines
2. Flu vaccines.
       The following measures were referred for further consideration:
1. Nurse staffing
2. Weight loss.
       These measures have not been adopted yet. However, this agency is the only agency making recommendations on this subject. All input flows through them. They also recommend the statistical analysis required to obtain these measures.
       Another item most clinicians feel is good news is the decision by CMS to allow paid “feeding assistants” in long-term care. These feeding assistants would have to pass a state approved training and testing program. They would work under the supervision of a licensed practical nurse (LPN) or a registered nurse (RN). There is a summary of the regulation and a link to the entire published regulation at the following website: http://www.cms.hhs.gov/providerupdate/regsum.asp. The exact publication you are looking for is CMS-2131F.
       It is in now up to the individual states to set up the required program for training and testing. So don’t look for these paid feeding assistants to show up on your unit any time soon. There are some consumer-based groups fighting the implementation of this ruling, which could also slow implementation. CMS has not announced its acceptance of these new quality measures. However, it is probable that CMS will accept these measures barring any legal action on the part of consumer-based organizations.
       A few months ago we posed the question, which do you work in, a long-term care facility or a nursing home? We have since received several responses, with about an even split, 50/50. Those favoring the use of the term “nursing home” believe it suggests a more caring and protective atmosphere. They point out it has been in use for years, and everyone knows what you are referring to when using the term. Advocates of this term are proud of the care they give to their residents.
       Those favoring the term “long-term care” believe it adds professionalism and respect to a long maligned industry. They see it as moving into the future and defining anew the field of endeavor they have chosen. Many of these respondents pointed out they care for a diverse population of residents. They also are proud of the care they provide.
       We are encouraged and optimistic due to the comments we have received. Of course, as stated in a previous column, we prefer the term long-term care. However, what we noticed most were healthcare workers busy and working hard to meet the needs of the residents they serve. They are concerned about the public perception of their occupation but seem to be so busy dealing with the day-to-day effort involved in providing care, they have little time for what to some appears as an esoteric debate.
       While we know you are all busy, it is not an esoteric question disconnected from the work being done every day in long-term care. If we do not define who and what we are, someone else will. Are we ready to submit to whatever the public or a government agency decides we are? As we said in our answer above, learn the definitions of the terms you are using. If nothing else has been pounded into our heads while working with the MDS, it is that everything needs to be defined before you can build on it. Our belief is that the term used to define us needs to include all of us. It needs to be broad enough to cover the many faces of long-term care.
       We believe societal changes begin at the ground level. While we respect those colleagues who use the term nursing home, we will continue to refer to the places where we work as long-term care or extended care facilities. We hope more of you will join us in this grass root change. If we have learned nothing else through our work with the MDS, it is that change is the only constant. Our goal should be to affect change, not merely respond to it. Until next time, keep the questions coming.
       If you have a question for Mabel, you can e-mail us at MabelMDS@aol.com.