Clinical difference of opinion on cognitive status with SS

[fulzgold]

I may be a little to picky about accuracy in coding but, I scheduled a Sig Chng on a res with End Stage Alzheimers who went hospice. She can no longer speak anything but gibberish, screams, hits, bites, kicks during care, stopped eating and drinking. 2 Staff perform her care while she beats them up and screams, they bring her out of her room all dressed and walk her down the hall. She is agitated. On rare occasion she will take a cookie if you catch her at the right time, but you don't know when that will be. certainly not enough intake to sustain life for long. Her facial expression is frozen in a look of pure fright, ( distressed). MD says at this stage, they don't actually experience hunger and thirst. All documentation is in place except for SS. SS never sees this woman, the rest of us hear her screams during routine cares throughout the day. SS goes in res room with a cookie in her hand, holds it up and says look at me. Res grabs the cookie and takes a bite then stuffs it under the covers. SS codes res for 2-Moderate impairment, because SS saw that as " making a decision." SS used NN to make her MDS documentation, and it supports a 3 Severe impairment, but SS sees the information as a 2. Now I am an RN, my medical training tells me this as a "severe cognitive impairment". I was under the impression the MDS Coordinator made the final call on codeing. SS hands in code for 2, I chose to code a 3 supported by the chart. Now I've been acused of "upcoding for money" and you name it, I'm just a delinquent. I was also under the impression that once a res codes in an Impaired cognition rug, the level of impairment 1-2-or 3,doesn't matter ( moneywise ), there is a set price for that. So what do you do? Go for accuracy and matching the record or grit your teeth and enter what the other disciplines code. By the way, My Activites Dir. fills out her section the exact same way for all residents. Its histerical. I mean we got blind people playing Bingo! board games!, and all sorts of neat stuff.> Well on paper anyway.

[Nascar nurse, ASN, RN]

I have been taught repeatedly that one should always code with information that accurately reflects actual resident condition. If the documentation does not agree with actual resident condition..always code resident condition, educate staff on better documentation and take the lumps that may occur with surveys when the info doesn't all agree. Also, as the RN, I've always been told that I get the final say, although I try really hard to make it a group decision.

[Ruas61, BSN, RN]

The MDS coordinator should be the one who stands ultimately IMHO.

[CapeCodMermaid, RN]

You are the final say...from what you've written, I'd code her a 3.

We had a resident who liked to go 'fishing' in the toilet and then eat the fish! The MDS coordinator had her as a 1! She just didn't get it. I don't think cognition plays a part in reimbursement, but it might affect your QI/QM results.

[silverbat]

Code the accurate condition of the resident. The documentation backs you up. You can add a nurses note yourself to note what you observe when you are on the unit, if you wish. The SS needs education on coding. Have you given him/her a copy of the section in the MDS 2.0 that discusses this? better yet, give her a copy of 3.0 and sho them what's coming down the road. IMHO--MY name is on the MDS, I take the lumps. If the documentation backs me up, I will code it. The same with activity. I enter it into the system, and if I disagree, I will put what the documentation states. If the blind person enjoys going to bingo and interacting, then that's fine. If she says the blind person is playing chess, I would argue that...although, come to think about it, I guess they could....

[glm777, BSN, RN]

If the documentation does not agree with actual resident condition..always code resident condition, educate staff on better documentation and take the lumps that may occur with surveys when the info doesn't all agree.

One thing that has saved me at survey time is this: anytime I find that the documentation does not accurately reflect the resident status and I code my MDS differently (accurately), I write a NN stating my findings of the resident's status. For example, SS coded a resident with no long term memory impairment. I see the resident every day in the dining room and she cannot remember where she lived prior to coming here, why she went into the hospital, where she worked for 40 years, etc. So I simply wrote a nurses note the date I was doing my MDS stating that I'd had a conversation with the resident and that she was unable to recall these things. Surveyors said this was fine.

[susanthomas1954]

One thing that has saved me at survey time is this: anytime I find that the documentation does not accurately reflect the resident status and I code my MDS differently (accurately), I write a NN stating my findings of the resident's status. For example, SS coded a resident with no long term memory impairment. I see the resident every day in the dining room and she cannot remember where she lived prior to coming here, why she went into the hospital, where she worked for 40 years, etc. So I simply wrote a nurses note the date I was doing my MDS stating that I'd had a conversation with the resident and that she was unable to recall these things. Surveyors said this was fine.

This is the only way to cover yourself. i do make it very loud and clear that I hate creating my own "source documentation," though. do you think this will change with 3.0? It seems we will be doing almost all our own source documentation.

The MDS coordinator has the final say, and bless anyone who has a team that all agrees. (I want whatever they serve at stand-up)

ST