Questions & answers from the American Association of Nurse Assessment Coordinators (AANAC).

Q: A resident was admitted in October. Weekly weights were in the chart as 165, 162, 167, and 163. He went to the hospital at the end of November and had a bilateral knee amputation. Upon return, his weight was 265. The weeklies that followed were approximately the same. His appearance is consistent with the 265 range. We have transmitted three MDSs, including a comprehensive assessment with weights in the 160 pound range, as that is what the chart indicated. Now we have scheduled a Significant Change because his amputation affected ADLs. Do we need to do a Significant Correction instead?

A: In this case, the Significant Change in Status Assessment (SCSA) is the correct assessment to complete. See the Correction Policy Flowchart on page 5-10 of the RAI User's Manual. You have described an uncorrected major error in a clinical assessment. In that case, if the resident's status meets the criteria for an SCSA, then the chart shows that is the assessment that must be performed. A new, current clinical assessment is needed when a major error occurs to ensure that the clinical data that the care plan is built upon are accurate. In cases where an SCSA is not indicated, the Significant Correction Assessment fills that need.

In addition to the SCSA, the modification process also must be completed to correct the error in the assessment that's already in the database. Although Chapter 5 of the RAI User's Manual summarizes the MDS Correction Policy, downloading the entire policy at www.qtso.com/mdsdownload.html is very helpful because it has more extensive explanations and scenarios that are useful in determining the proper steps to take depending on the nature of the error.

Q: When a resident exhausts Part A benefits, does admission to an acute hospital interrupt the count toward the 60-day break in skilled services?

A: Yes. Because hospital care is a skilled level of care under Medicare Part A, an inpatient hospital stay interrupts the count toward the 60-day break in skilled level of care. From the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Section 10.4.2: "The benefit period ends with the close of a period of 60 consecutive days during which the patient was neither an inpatient of a hospital nor of a SNF."

Q: A 98-year-old resident was admitted with a Stage IV pressure ulcer on the spine (kyphotic prominence). Originally, she'd had surgery to evacuate an epidural hematoma that developed from a "spinal" for pain. Following this, the woman was discharged to home to be cared for by her daughter. The area did not heal and became infected, and now she is in a Part A stay with us. Is it correct that it should be coded as a pressure ulcer, even if it began as a surgical wound that did not heal, if it is on a bony prominence?

A: No, it isn't. The location of the wound is not the determining factor in deciding if an ulcer should be coded as a pressure ulcer. If pressure was a contributing factor to development of the ulcer, then it should be coded as a pressure ulcer. The definition on page 3-161 says: "Pressure Ulcer--Any lesion caused by pressure resulting in damage of underlying tissues."

A nonhealing surgical wound would be coded as a surgical wound regardless of location. If pressure contributes to the healing problems, then the care plan certainly should address this problem. However, since the MDS instructions are to code an ulcer in either M2a or M4, but not both (p. 3-167), the MDS code for this ulcer would be "surgical wound."

Q: If staff are bringing the food to the resident, and do no other setup, can they code "0" and "1" on the ADL flow sheet for Self-Performance and Support in Section G1? Some staff members are arguing that this is a form of facility setup, so they want to code "0" and "1." Also, many staff are coding "1" and "1" for eating, because they bring them the tray and intermittently check on them to encourage them to drink or eat more.

A: How the food gets to the resident is not a part of the eating activity for G1h. The resident described in the first example would be coded 0/0. See the example on page 3-83 of the RAI User's Manual. General supervision of residents in the dining room is not considered to be oversight or cueing for MDS purposes. If a resident needs oversight and cueing and therefore a staff member intermittently returns to prompt the resident, then this would be captured as a "1" for ADL Self-Performance.

Q: How do we look at weight bearing for dressing? Is it lifting the arm or leg to put in the sleeve? What do we call buttoning buttons or fasteners? There are so many parts to dressing; how do we look at performance of the various parts?

A: A task that involves lifting the resident or a part of the resident is a weight-bearing task. Buttoning buttons or closing fasteners is a part of one of the subtasks of dressing or toilet use (putting on pants, for example) and would be considered non-weight-bearing physical assistance. This is illustrated in the Toilet Use example on page 3-85 of the RAI User's Manual. When an entire subtask of an ADL activity is performed for the resident, such as shaving or hair combing/brushing/styling as subtasks of Personal Hygiene, it is considered to be extensive assistance. See the last two examples on page 3-100.

Q: A Medicare Part A resident was in the facility for 10 days. The 5-day Assessment was done as AA8a = 0/AA8b = 1. The discharge tracking coded was 08, discharged prior to completion of initial assessment. The resident returned a week later. Since the discharge tracking code did not anticipate return one way or another, do I keep the original admission date in AB1 or do I enter the new admission date? If I keep the original AB1 date, don't I get a warning message because completion will be more than 14 days from the AB1 date?

A: The original date of entry is used for all readmissions when the discharge tracking code was an 8, discharged prior to completing initial assessment. This information can be found on page 2-24, paragraph 5, of the RAI User's Manual. A date is not entered in A4a until a readmission occurs after a discharge with return anticipated. The warning message is provided as an alert to flag a possible problem and not as an implied instruction to enter a date contrary to the published coding rules.

With thanks to Rena Shephard, MHA, RN, FACDONA, AANAC Chair, and President of RRS Healthcare Consulting Services, San Diego.