ADLs

[ibtootie]

First I just need to blow my stack that no matter how much I instruct and educate the Unit Assistants on ADL documentation, they still either don't get it or don't care to get it. No matter how much I complain to the Nursing Director about it, either she too doesn't get the importance of it, or she doesn't want to!

That being said, Mrs. X was admitted to our facility for rehab after a total knee arthroplasty. She was in our facility 7 days and had 8 different UA's assigned to her. Of that 8, only 2 actually documented ADLs. "Bob" is one of the night UAs and had her 2 nights. His documentation is pretty accurate, and coincides with the Nurses and Therapists documentation. "Sherry" is one of the day UAs who had her for 3 days, and her documentation is rarely ever accurate. She often combines self performance and support in ways that are not even logical, such as independent and 2 person physical assist, so most of the time I cant use any of her documentation. I have instructed her and reinstructed her until I am blue in the face, and it doesn't seem to sink in with her.

My problem is that there were only five entries for ADLs, and only 2 of those 5 entries could be used. Technically there were more than 3 episodes ADL documentation, but I don't feel comfortable submitting what there is since I know it isn't accurate. Has anyone else ever experienced this, and if so, how did you handle it?

[Talino]

My problem is that there were only five entries for ADLs, and only 2 of those 5 entries could be used. Technically there were more than 3 episodes ADL documentation, but I don't feel comfortable submitting what there is since I know it isn't accurate

In such case, you can interview the actual caregiver and have him/her explain to you what the resident actually did and what he/she did. You can then reeducate the caregiver and have him/her enter or recode the ADL. You can also enter the correct codes yourself after a caregiver's statement of actual event. Simply document the reason for doing so.

CMS does not impose specific documentation procedures on nursing homes in completing

the RAI. Direct care staff interview is just as valid as what is written in black and white. Moreso, when you attested to have obtained that information truthfully when you signed Section Z.