The MDS’s impact on quality of care and quality of life

Most of the roles of the Minimum Data Set (MDS) are well-known and frequently discussed in the nursing home arena—care plan development, Medicare and Medicaid reimbursement and quality monitoring via the Quality Measure. Another critical function for this federally mandated assessment tool, though, seems to be largely unrecognized: It can provide significant clues to the quality of the care provided by the facility and to the quality of life experienced by the residents. As such, for nursing home providers, the MDS can be a valuable tool for quality improvement activities; for surveyors, it can help to identify quality of care and quality of life deficiencies as part of the survey process.

Most nursing home providers understand the importance of auditing the MDS against the medical record to ensure that the chart supports the coding decisions represented on the MDS. But analyzing MDS responses in the context of quality seems to be a missed opportunity for many providers.

For example, a language barrier can lead to poor care because of limited communication between the resident and caregivers and also to social isolation and depression. MDS item A1100, Language, asks whether the resident needs or wants an interpreter to communicate with a doctor or healthcare staff. If there is a language barrier and this item is answered with a 0, No, and a translator is not provided, it is likely that the communication items in section B, Makes Self Understood (B0700) and Ability to Understand Others (B0800), will indicate a significant communication problem. This should be viewed as a red flag.

Every resident who has the functional ability to do so should be able to communicate requests, needs and opinions, and engage in social conversation as well as understand what is said to him or her. The use of rudimentary hand signals or other basic methods to indicate need for assistance, such as help with toileting or eating, is not sufficient. A language barrier (or a hearing deficit or expressive aphasia, as other examples) should not be an obstacle to communication if interventions which overcome it are available and acceptable to the resident. Analysis of MDS responses can help to ensure quality in this regard.

Another way the MDS can help in identifying possible quality of life and quality of care deficiencies is through correlation of the responses in section F, Preferences for Customary Routine and Activities, with the care plan and, if the care plan is appropriate, with evidence of implementation of the care plan. Be sure also to investigate possible relationships between:

• Depression and resident’s preferences not being honored
• Sleep problems and a bedtime that is too early or too late for the resident (F0400E)
• Irritability and/or depression in the context of the need for snacks (F0400D)

When it comes to restlessness and irritability, check to see if the resident is accustomed to being busy with reading or listening to music or enjoying the outdoors or other favorite activities (F0500), but is not staying busy with activities that are meaningful to him or her while in the nursing home. Also, it would certainly be a red flag if the resident were taking psychoactive medications and then to have these kinds of issues be revealed, possibly in the survey process, as the underlying cause of the problem.

Section L, Oral/Dental Status, can be a significant risk area for the resident and the facility if the examination of the oral cavity is not conducted thoroughly. It is wise for nursing supervisors to spot check the resident’s oral cavities and check the accuracy of the MDS. Here is an example of what happened when this was missed:

• A diabetic resident’s blood sugar was chronically difficult to control. He generally received routine insulin plus coverage at least twice per day.
• The resident became lethargic over several days. His blood sugar still was difficult to control and finally spiked to >600. He was sent to the hospital.
• Review of the case found that the facility failed to properly assess oral status and identify infection, which exacerbated the blood sugar problem and also resulted in bacterial pneumonia
• Also, when thorough evaluation of the oral cavity revealed evidence of a problem that could adversely affect the resident’s health, the chart should show immediate follow-up with the appropriate healthcare provider.

Falls are another area where the MDS can be very helpful. Most facilities use a screening tool to identify the individual’s risk for falling. Those screening tools, however, are not assessments—they are designed to precede a full fall risk assessment if risk factors are identified via the screening. The MDS provides valuable information about a resident’s risk for falling, and it is very meaningful information, since, unlike most fall risk screening tools, the coding is based on specific definitions, resident characteristics and requirements for completing the items. The items most helpful in identifying risk for falls include:

• ADLs (G0110)
• Balance (G0300)
• Wandering (E1000)
• Signs/symptoms of delirium (C1300)
• Antianxiety (N0410B) and Antidepressant (N0410C)
• Fall since admission or prior assessment (whichever is most recent) (J1800)

Thus, correlation of the coding decisions for the above items with the conclusions and care planning about the resident’s risk for falls can be a helpful quality check.

But the real key to uncovering a resident’s risks for falling is in the Care Area Assessment (CAA). If the Falls CAA triggered when the assessment was completed, the reviewer should evaluate whether this follow-up assessment was thorough. If CAA did not trigger but risk was identified via a screening tool, the auditor should determine whether thorough assessment such as the Falls CAA was completed to identify root causes, contributing factors, risk factors, etc.

In fact, the CAA, as the detailed, in-depth assessment, is really the key to high quality care in any of the 20 areas of health status involved. When a CAA is triggered and the assessment of the care area is conducted in the detail required by whatever evidence-based or expert-endorsed tool the facility opts to use, it becomes relatively easy for a skilled assessor to identify the root causes and contributing and risk factors specific to the individual resident, and the appropriate care plan flows from that information. It is critical to ensure that this process is proceeding as required every time a CAA is triggered. Here is an example of what can happen when it doesn’t:

• Acute Onset Mental Status Change (C1600) triggered the Delirium CAA
• The facility assessed for infection but failed to use a current, evidence-based or expert-endorsed Delirium assessment tool as a guide
• UTI was identified, appropriate treatment was implemented
• The resident’s low sodium level and her newly increased dose of Remeron were missed as possible causes of the delirium
• Her confusion continued; functional decline, incontinence, nutritional deficits, debility resulted. She hit her head falling out of a wheelchair and died from head injury.

The MDS provides a plethora of valuable information about the resident. Analysis of the quality of care and quality of life issues reflected by the MDS, such as the few examples discussed in this article, should be integrated into the facility’s systematic quality improvement processes. Significant benefits can ensue for the resident and for the facility.               

Rena R. Shephard, MHA, RN, RAC-MT, C-NE, is president of RRS Healthcare Consulting Services, San Diego, which provides consulting and training services to long-term care facilities, corporations and attorneys nationwide. She serves as a content expert on AANAC’s Expert Advisory Panel and as an author and reviewer for many of  AANAC’s certification courses. Contact her at RRS2000@aol.com.