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pring is here again, and everything seems to be changing—including the Minimum Data Set (MDS). Everyone is talking about the changes to the Resident Assessment Instrument (RAI) manual and how to get ready for them before June 15, but we will discuss this in greater detail later. Let us answer a question first.
       “Dear Mabel: We just admitted a resident from a sister facility. Since I did the pre-admission assessment, I knew what the resident’s resource utilization group (RUG) had been at the previous facility. When we completed the admission MDS on the resident, our RUG was higher than the previous RUG at the other facility. I don’t understand how this could be, because the resident did not change. What happened?” (registered nurse, Texas)
       Answer: Unfortunately, we have seen this before. While it is true that the MDS is supposed to be a reproducible assessment (ie, all trained clinicians should be able to produce the same result using the same resident and assessment reference period), sometimes it just does not happen. There are several reasons for this.
       The first and most obvious reason is that not everyone who completes the MDS has read and understood the definitions for every entry he or she made on the MDS. Every blank on the MDS is defined. It has to be. The prime example we often use is incontinence. As a nurse, someone who has a catheter is considered incontinent. Just ask any nurse, and he or she will tell you anyone who uses a catheter is incontinent.
       This is not so for the MDS. The MDS defines continence as being dry. Although simple and straightforward, this definition runs counter to all nursing definitions for incontinence. This definition means that if a resident has a catheter, he or she is therefore dry and continent. If the clinician has not read the definitions and is relying on his or her good judgment and education, however, the clinician will incorrectly code the resident as incontinent. The MDS will be wrong. The RUG will be wrong. The reimbursement may even be wrong. It is a sorry cascade of events.
       Another area ripe for errors is documentation. Since the MDS has also turned into a reimbursement tool for Medicare Part A and, in some states, Medicaid, entries on the MDS must be validated in the chart. The MDS is no longer considered a source record by the federal government. In other words, everything on the MDS must be backed up by entries elsewhere in the clinical record.
       So, if the resident’s previous facility had poor record keeping, it would make sense that you captured more elements that “RUGGED.” “RUGGED” has now become a technical term meaning factors or elements that affect the case mix score or RUG. There are as many forms to gather required documentation as there are long-term care facilities. Everyone has his or her own preferred method. Several long-term care corporations have introduced their own copyrighted method. Other corporations that manufacture forms have also developed tools to collect data. All do the same thing—gather data.
       The problem is in the complexity of these forms and the education of staff in using these forms. All staff using the form must be educated, and this education must occur at frequent intervals. It is not because staff lacks the ability to comprehend the form, but because staff changes, forms change, and the MDS changes. The people completing these forms or performing the documentation are usually licensed or certified. They have proven they have the ability to learn. So, hang in there and trust them.
       Next, we have the complexity of the forms. When and if you get a chance to choose these forms, always think of the person completing them, and ask yourself, “Could I do it and complete all my other assigned tasks?” It is fortunate (and also unfortunate) that when a clinician must choose between paperwork and resident care and well being, he or she will always choose the latter. So keep that in mind when designing a system to collect data.
       We would like to pass on a small pearl you may find helpful: try to emphasize to your staff the data they will be gathering pertains to the past and never the future. If you use any form of a “summary,” you need to drop that term. Written notes for MDS data are not summaries. Try using the phrase, “MDS documentation.” For example, you often will see, “Resident eats per self.” But what does that really tell? The MDS wants to know whether the resident ate independently, not if he or she might eat in the future, as the previous sentence predicts. A better statement might be, “Resident ate 100% of supper per self.” That reflects what really happened. We preach it all the time: past tense.
       The RUG, or RUG III for version 3, according to the RAI, is “a category-based classification system in which nursing facility residents classify into 1 of 44 or 34 RUG III groups. Residents in each group utilize similar groups and patterns of resources. Assignment of a resident to an RUG III group is based on certain item responses on the MDS. Medicare uses the 44-group classification. Many state Medicaid programs use the 34-group classification.”
       As we have previously stressed, documentation is key to capturing all the elements necessary to classify a resident into the most appropriate RUG. Accurate observations and documentation should be recorded in the chart in the past tense. Like other team members, the MDS coordinator may also record his or her observations.
       As a team member, the MDS coordinator must remember that it takes a team to care for a resident. There is no doubt that psychosocial issues affect the care of every resident. Imagine a resident with a respiratory problem who is anxious. Not only would the staff members acknowledge the problem, they would also try to reassure the resident while instituting measures to relieve the anxiety. This also applies to residents with dementia. Many people who have Alzheimer’s disease also wander. Many of us have cared for others who, in a vulnerable state, require reassurance after lashing out or expressing depression or fears. And pressure ulcers, which involve nursing, dietary, social services, therapy, and even pharmacy, are another example of a team effort. Every member of the team plays a valuable part of the care. Even the administration in a building affects patient care by providing leadership. Every person in the building somehow affects the care of every resident, whether providing direct care or not. Even though the landscaper is not a caregiver, the grounds provide atmosphere for residents when they go outside or when family members come to visit.
       This holistic approach is recorded in the MDS. While each member of the team completes his or her own section, it is obvious that everyone contributes information that truly reflects the resident. Many facilities review several items on the MDS as a team in order to capture the accuracy of the MDS.

MDS News

       The changes to the RAI manual that will become effective June 15, 2005, affect 3 main areas of the MDS and correct some typos. The first notable change addresses the use of electronic signatures. Basically, old language is deleted and new language substituted. There does not seem to be a lot of significance to this change; it is just an update to accept and further clarify the use of electronic signatures.
       One of the biggest changes is to Section K, which is Oral/Nutritional Status, and specifically K5a, Parenteral/IV. You can count the fluid mixed with an intravenous antibiotic as a nutritional approach, but now it must be documented by a physician that the fluid given is actually part of a nutritional approach to give fluids.
       The other big change is to Section M, Skin Condition. It will no longer be required to stage all disease-related ulcers in section M1. The only ulcers that will be staged here are pressure ulcers and ulcers caused by circulatory problems. Two case studies are offered as learning models. The instructions are clearer and better illustrated by the examples. Be sure to revisit the website if you picked up the changes soon after they were released. There were a few typos in the new changes, and CMS has removed them in the new release.
       We wish you the best keeping up with all the changes—in life, in the seasons, and in the MDS world. Keep those questions coming.

       If you have a question for Mabel, you can e-mail us at MabelMDS@aol.com.